Antipsychotic Use in Nursing Homes: Balancing Medication Safety, Policy, and Dementia Care

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In this episode, Lauren Gerlach and Matt Davis speak with Theresa Shireman, PhD, Director of the Center for Gerontology and Healthcare Research and a Professor of Health Services, Policy and Practice and Epidemiology at the Brown University School of Public Health. Dr. Shireman’s research focuses on pharmaceutical policy, pharmacoepidemiology, health services research, and medication use among vulnerable populations.

Dr. Shireman discusses her recent study, "Impact of Federal Antipsychotic Use Policy in Nursing Homes on New Diagnoses for Approved Indications in Dementia Residents," published in the Journal of the American Geriatrics Society. The study examines whether federal policies designed to reduce antipsychotic use in nursing homes were associated with increases in new diagnoses of conditions, such as schizophrenia, that exclude residents from publicly report antipsychotic quality measures.   Using an interrupted time-series design, the researchers examined changes following the 2012 National Partnership to Improve Dementia Care and the 2015 addition of antipsychotic use to the Nursing home Five-Star Quality Rating System. They found that neither policy was associated with an increase in new exclusionary diagnoses, challenging concerns that nursing homes were increasingly assigning these diagnoses to circumvent restrictions on antipsychotic use.

The conversation also explores the benefits and risks of antipsychotic medications for people living with dementia, including the potential for serious adverse effects such as sedation, falls, stroke, and increased mortality. Dr. Shireman discusses how public reporting and financial incentives can influence prescribing practices, the limitations of using a single quality measure to evaluate nursing home care, and the importance of balancing medication safety and residents' individual needs. The discussion highlights the need for shared decision-making among clinicians, nursing home staff, residents, and families, as well as greater investment in staffing, resources, and nonpharmacological approaches to improve quality of life for people living with dementia. The transcript for this episode can be found here. 

Article Discussed in the Episode:  

Shireman TI, Coulibaly N, Zhang T, et al. Impact of federal antipsychotic use policy in nursing homes on new diagnoses for approved indications in dementia residents. J Am Geriatr Soc. 2024; 72(12): 3742-3752. doi:10.1111/jgs.19129

Transcript

Lauren Gerlach:

Welcome back! So today we're talking about an important and complicated issue in dementia care, the use of antipsychotic medications among nursing home residents living with dementia.

So, why is this important? In nursing homes, few medication classes have received as much regulatory attention as antipsychotics. These medications are frequently used to manage behavioral symptoms of dementia, which can include symptoms such as agitation, aggression, or psychosis. But their benefits are often only modest, and their risk can be serious, including side effects such as sedation, falls, stroke, and increased mortality. And because of these concerns, there's been several federal efforts that have been aimed to reduce potentially inappropriate antipsychotic use through public reporting, quality measurement, and the five star quality rating system in nursing homes. But as with many healthcare policies, the story is not always straightforward. When a quality measures focuses on reducing one type of medication use, it may change prescribing in ways that improve care, but it might also create incentives that affect documentation, diagnostic coding, or substitution with other medication classes.

Today, we'll talk about why antipsychotic use is monitored in nursing home settings, what these policies were designed to do, and how new research helps refine our understanding of both the intended and unintended consequences of antipsychotic quality measures.

Matt Davis:

Welcome to Minding Memory, a podcast devoted to exploring research on Alzheimer's disease and other related dementias. Here, we'll discuss some of the most compelling research and talk with leaders in the field about how their work is improving the detection and treatment of dementia. I'm Matt Davis.

Lauren Gerlach:

And I'm Lauren Gerlach.

Matt Davis:

We're both researchers at the University of Michigan. I have a PhD in data science.

Lauren Gerlach:

And I'm a geriatric psychiatrist who specializes in diagnosis and management of dementia.

Matt Davis:

I'll work to minimize the use of medical jargon in our discussions.

Lauren Gerlach:

And I'll make sure that the research we talk about has practical, real world applications to people living with dementia and their care partners.

Matt Davis:

Thanks for joining us, and let's get started.

Lauren Gerlach:

Today, we're very fortunate to be joined by Dr. Theresa Shireman. Dr. Shireman is the Director of the Center for Gerontology and Healthcare Research, as well as a Professor of Health services, Policy and Practice, and Epidemiology at the Brown University School of Public Health. Her work focuses on pharmaceutical policy, pharmacoepidemiology, health services research, and medication use in vulnerable populations.

Today, we'll be talking about an article of Dr. Shireman's, The Impact of Federal Antipsychotic Use Policy in Nursing Homes on New Diagnoses for Approved Indications in Dementia Residents. This was published in the Journal of the American Geriatric Society. The study examined whether federal policies targeting antipsychotic use in nursing homes were associated with changes in new diagnoses that exclude residents from the antipsychotic quality measure. Theresa, welcome to Minding Memory. We're so glad to have you here.

Theresa Shireman:

Thank you, Lauren, and I'm really pleased to be here.

Lauren Gerlach:

So, we'll start off with just learning a little bit about you. So to start, could you tell our listeners a bit about yourself and how you came to study medication use and pharmaceutical policy?

Theresa Shireman:

So I was actually a certified nurse's aide in a nursing home at the end of high school, and I became very interested in the medications that residents were receiving at that time. I went on to pharmacy school and became a clinical pharmacist and am now a pharmaceutical health services researcher, as you pointed out. So my interest in medication use in older adults has been an important part of my career since high school, I would say.

This topic in particular hits me personally, as both of my parents had dementia. And as a family with several healthcare professionals, including physicians, nurses, and physical therapists, we had an inordinate amount of trouble trying to get my parents off of psychotropic medications once they were institutionalized. And my mother in particular was put on risperidone and gained a lot of weight and she became non-communicative, and it was just really heartbreaking. And we felt so powerless to try to change what we knew was really not the best practice.

Lauren Gerlach:

Thanks for sharing part of that story. I think for many individuals working with older adults or dementia care, there's often a personal connection that brings people to the field. So, I think that's a common thread we see when we talk to folks here.

Matt Davis:

So before we get into your study, I was wondering if you could give listeners a little bit of background on antipsychotic use in nursing homes, and specifically why it's received so much attention.

Theresa Shireman:

Yeah. So I think Lauren touched on some of this in her opening comments, but in my view, antipsychotics are actually one of the most effective therapeutic agents we have, therapeutic classes we have in the market. And for people with serious mental illness, they have allowed people to be released from long-term institutions. They've allowed people to live normal, productive lives, be engaged in the workforce. But they also have really, really some significant side effects. And those side effects have changed as newer classes, subclasses of antipsychotics have come along. But these side effects are more pronounced in older adults for the reasons that we would expect. They have altered pharmacokinetic and altered pharmacodynamic properties. They're not able to metabolize the meds the same way. They have smaller volumes of distribution. It's easier for an older adult to face toxicity from these drugs.

For nursing homes, the decision to use antipsychotics is often driven by staff, and these are the staff who are directly encountering challenging behaviors with the residents. And it's up to the staff to protect the resident from self-harm, it's up to the staff to protect the resident from harming others, including the staff and other residents. And that harm can be life-threatening, there's no doubt about it.

So it's in my mind, antipsychotics can play a really important role in the care of older adults in nursing homes, but it can also be a false protector. It can also be something that you don't want to rely on antipsychotics to address harm if you don't have to. And because these antipsychotics cause severe harm to the individual themselves by virtue of significant weight gain, by changes in their metabolic profile. These drugs, the early first generation antipsychotics were known to have permanent disabling effects, such as tardive dyskinesias. The second generations have fewer of these side effects, but they still have a lot of risk for older adults, which ultimately can lead to falls, to heart attacks, to strokes, presumably, and other kinds of premature mortality that you really want to stay away from.

So for any facility, because you're in an institutionalized setting, the staff have to make decisions and they have to make decisions based on what they're facing on a day-to-day basis. And whether it's, do they have enough resources to try to control disruptive behaviors? Or are they spread so thin that they need to rely on other things that they know are going to work? They're going to sedate the person, they're going to take them out of harm's way in that sense. But there were concerns in as early as the '80s, where people thought nursing home residents were getting too many of these drugs and that the staff were becoming more and more reliant on antipsychotics as a way to control behaviors of individuals. And that led to one of the earliest policies was over 1987 where they said that we saw the first regulation for unnecessary antipsychotic use in nursing home residents.

And actually, interestingly enough, that grant. The grant that we wrote this paper on was contributed to by a paper that a colleague of mine did back in 19... or grant that a colleague of mine did back in 1987 in a response to this high use of antipsychotics.

Matt Davis:

And could you talk about the relevance specifically to the dementia population?

Theresa Shireman:

The harms to dementia residents or to dementia patients are particularly pronounced because they are used so highly in those agents. And there have been a couple of studies that have shown that the rates of adverse consequences is much higher in dementia. This led to two black box warnings from the Federal Food and Drug Administration, the FDA. The first black box warning came out in 2005, which was largely targeted towards the first generation antipsychotics. And that was followed by an updated black box warning in 2008 that included the second generation antipsychotics. So those were explicit recognition by the FDA that, and I think it was largely based on a CATIE Trial. You can verify that, Lauren, where they showed that these drugs caused more harm than good, particularly in dementia residents.

Lauren Gerlach:

That's exactly right. I think after the CATIE Trial and several pooled meta analyses, they were seeing increased harms basically in the group of residents receiving these types of sedative medications versus placebo, and increased the concern regarding cardiovascular side effects, stroke, and premature mortality.

You talked about some of the initiatives with OBRA in the 1980s. I was hoping you could walk us through a little bit the landscape of some of the more recent federal policies or initiatives aimed at reducing antipsychotic use in nursing homes.

Theresa Shireman:

Yeah. So the two that I'll highlight are the ones that we talk about in the paper. The first is the 2012 National Partnership to Improve Dementia Care, and then it was followed in 2015 by a five-star quality rating program. So the national partnership was actually a... so, CMS has great oversight, broad oversight of nursing home care in the United States. And if a nursing home wants to receive money from Medicare or Medicaid, then they have to participate in this initiative. The Partnership to Improve Dementia Care was a voluntary initiative, initially. It was to try to get nursing homes, they had a target of trying to reduce antipsychotic use in nursing home residents by 25% or 50% or something like that. They had a benchmark that they were shooting for, which they actually met.

And so, but the partnership was really, was I think even exclusively focused on antipsychotic as the measure of outcome that they were trying to achieve a reduction in use. But nursing homes were given a packet of tools and encouraged to work with their quality improvement organizations and encouraged to work with their professional associations to try to figure out ways to better manage these patients who were using antipsychotics on to find other kind of behavioral interventions and other tools to reduce use. So the partnership was designed to reduce antipsychotic use on a voluntary basis.

They put teeth into that in 2015 when they set up an explicit measure of antipsychotic use in nursing home residents, in the patients with dementia in nursing homes, and that is reported publicly as part of the nursing home quality. There's a five-star quality rating program for nursing homes, and this is one of the key measures in that. So you can go online and look up in nursinghome.com or nursinghomecompare.com or .org, I don't remember what the extension is. You can explicitly look at for a given facility, what is their rate of antipsychotic use? So, that added teeth to this quote "voluntary" initiative that occurred in 2012.

Matt Davis:

I find it so interesting that the benchmark they came up with, it sort of implies that we just want to reduce. I mean, I'm assuming that there's a mix of appropriate and inappropriate use. So, how do you wrap your head around just coming up with a benchmark on just reducing it? I mean, is it a good thing from your perspective in terms of the benchmark that they set, or I guess thoughts about how you come around with that sort of policy recommendation?

Theresa Shireman:

It gives you something very concrete that you can measure. And you can say, "Did they get this? Did they reduce use? Did they reduce it by a certain amount?" It's something that's really, really visible to people. And I think that's happening in healthcare in a lot of places. There's a lot of quality measures where we think everybody with diabetes needs a hemoglobin A1C checked every year, right? And it allows insurers or third parties of any sort to look and say, "Is this person or is this practice providing the right level of care?"

But in my opinion, giving antipsychotics to nursing homes residents really should involve shared decision making between the staff and a prescribing physician, as well as with the family and caregivers, otherwise. The goal of the staff and the physician theoretically is to reduce harm to patients and to others. I'm not always sure that including family in that discussion is going to change the decision process. It certainly didn't for us. My family was very involved in trying to get the decision changed on my mother being on antipsychotics, for instance. But I think that the prescribing physician and the staff really have to think very carefully about the pluses and minuses of doing that therapy. And when you have an externally applied metric and a metric that carries financial penalties for the facility because their reimbursement rate can go down if their quality rating goes down, once you start tying it to those financial incentives, it has more teeth, but it also takes things out of the hands of the practitioners who are there on a day-to-day basis and can know what they should do.

Facilities to me, facilities that have a high rate, high rate being relative, of antipsychotic use, it's a signal that something else might not be working right. It could be that they just have a lot of patients who really have a lot of behavioral issues and maybe have a diagnosis that's not excluded. We didn't talk about exclusionary diagnosis yet, but that hasn't been excluded from the metrics. I think of bipolar patients who really do need an antipsychotic, but they're in a gray area.

So, some people think that this high rate of antipsychotic use says it's a bad nursing home and that they should be trying to deploy other kinds of approaches. But that's what the Five-Star Rating does, is it makes this stuff really explicit for people. It's measurable, people can see it. They can say, "This facility has this rate, this facility has this rate. I want my parents in this lower rate facility because something's better there." But it doesn't give you a comprehensive picture of what's going on in the facility.

Matt Davis:

So you've touched on this a little bit, but from a policy standpoint, is there a specific theory behind monitoring antipsychotic use?

Lauren Gerlach:

Or maybe even like in the idea about how that might change prescribing and like incentivizing, as you were saying, or patients or families will choose facilities based on this or financial... I guess, may have covered part of that, but thinking about how that motivates physicians or prescribers to change behavior.

Theresa Shireman:

It's going to lead to... It does reduce, I think it has been shown to reduce antipsychotic use that they induced this policy.

What we saw in some of our work, Lauren, not in this particular study, but was that people start using other medications that may have similar sedating effect or that are other kinds of "chemical restraints" as we call them. So there's incentives to find another way to avoid the scrutiny of the policy itself, but it may not necessarily be helpful. It may not prevent the harms that we've been worried about.

Lauren Gerlach:

Before we jump into this specific study, could you just orient us to how CMS constructs this measure? So, who are the people included and what goes into this measurement that is then publicly reported?

Theresa Shireman:

Yeah. So the measures, or the proportion of the population with dementia who is on an antipsychotic. And they take out of the denominator of that, they take out people who have what's called an exclusionary diagnosis, and I briefly referred to this earlier.

The exclusionary diagnoses are diagnoses by the government has agreed that the benefits of antipsychotic use in these populations outweighs the risk. And those medications are, or those conditions are schizophrenia, Huntington's disease, and Tourette's syndrome. And Tourette's and Huntington's are incredibly rare, very, very rare. The vast majority of the people that have an exclusionary diagnosis have so because they have schizophrenia. And schizophrenia is a severe psychosis condition, it's generally lifelong, onsets in the 20s and 30s. So, it's an early diagnosis largely for these kinds of conditions. You're not going to see many people diagnosed with schizophrenia in old age per se, which is really important in the context of our study. It's something that they're going to have lived with for many, many years.

So the partnership and the quality measure is going to take out of the denominator anybody who has a serious mental illness like schizophrenia, not so many people are going to be misdiagnosed with Tourette's or Huntington's. And what happens is if you do that, then the nursing home, if they have somebody who has aggressive behavior or is neuropsychiatric symptoms of some sort, then if the nursing home can just label them as having schizophrenia, then it allows them to not have to have the same... then their antipsychotic rate won't appear to be so high because they'll take those people out of the numerator and the denominator, in fact. Right? But if they can say, "Oh, this person really has schizophrenia. We're using this drug appropriately, the antipsychotic appropriately," that's what people have been worried about.

Matt Davis:

And unfortunately, that's plausible. I mean, we see those kinds of things happen in US healthcare systems. I mean, it's possible, unfortunately. So I guess turning to your study now, what was the main question that you wanted to answer in your study?

Theresa Shireman:

So we were seeing reports both in the lay press as well as some published journal articles that said that in fact, this rate of exclusionary diagnosis was going up. That nursing homes were ascribing these diagnoses to dementia patients in order to be able to use antipsychotics. We were seeing this, it was being reported. There's I think a famous New York Times article that came out called The Drugging of Nursing Home Residents, something along those lines.

And again, given the backdrop that schizophrenia is unlikely to start when somebody's in middle age and older as a new diagnosis, it didn't really... What I wanted to know was if somebody went into a nursing home... So all the studies have been done, we're looking at prevalent nursing home patients, everybody who was in a nursing home. And you couldn't figure out if they had schizophrenia before they came in a nursing home, based on the way that they did their studies. And what we wanted to do was, let's back it up a little bit and say, did they have schizophrenia at the time that they were admitted to the nursing home?

And so we designed it to say, okay, let's take out the people who didn't have schizophrenia before they came into the nursing home. They did have dementia, we knew they had dementia. And how many were given a new diagnosis of schizophrenia after they landed in a nursing home? And that would be a better indicator of our facilities changing their behaviors and ramping up this diagnosis of schizophrenia or... I'm going to focus on schizophrenia again, because Huntington's and Tourette's are just little teeny tiny and the numbers don't change on those, but that were nursing homes doing this trade of ascribing more schizophrenia after somebody had been in a nursing home in order to use antipsychotics, presumably.

Matt Davis:

Yeah. And why was it specifically important to look among residents with dementia?

Theresa Shireman:

Because the metric applies. The quality measure applies to people with dementia. So the national partnership, everything, it was the rate of antipsychotic use in dementia residents.

Matt Davis:

Okay. Can you just give us a broad overview of your study design?

Theresa Shireman:

Yeah. So what I was saying is, we wanted to look at people who became what we call in the field, long-term nursing home residents. So they weren't just there after a hospital event or there for a short period of time, they were going to stay in a nursing home. And we defined that in the field as 100 days or more in a nursing home and that's when you qualify as a long-term resident.

And we wanted to look at three time periods. One was before the 2012 National Partnership. The second time period was between the 2012 Partnership and the 2015 quality, the changes to the quality measure, and then after the 2015 quality measure. So we had three windows of time that we looked at. Who became a new, long stay nursing home resident in one of those times? And did they acquire a new diagnosis of schizophrenia, Tourette's, or Huntington's? But did they acquire one of these new exclusionary diagnosis?

And what we did was we said, "These are conditions that you are going to be seen for on a regular basis, medically." And so we required at least two years of no time, that they didn't have any claim, any medical visit that said they had one of those three conditions. So we have what's called a two-year washout window before they became a long stay nursing home resident. So that's a pretty good... There might still be a few people who had one of these conditions and hadn't been quote "treated" for it for three or four years. But in talking with my geri-psych person on the team, we determined that two years is long enough to figure out if the person was actively being treated for one of these conditions.

And then we followed them. After they were admitted, we looked out for two years and we looked to see if they suddenly ended up with a diagnosis of schizophrenia, or Huntington's, or Tourette's, but schizophrenia was the largest part of it. So that was to us a better indicator of, are they acquiring new diagnoses once they've been admitted to the nursing home? Right? Does that make sense?

Matt Davis:

Yeah. And you specifically used an interrupted time series, which from my understanding is set up nicely for a before, after, sort of situation.

Theresa Shireman:

Yeah. So we could say, what was the rate before the 2012 policy? What was the rate between the 2012 and 2015 policy? And what was the rate after 2015?" And also, in 2012 and 2015, did the rates jump? Was there a one-time jump? Because sometimes facilities will, in policy, sometimes in anticipation of a rule change, the entity may change its behavior and so you'll see a change in the metric in that point in time.

And in another work that we did, we showed that we've also looked at antipsychotic use in those three windows of time. And I'll largely say, antipsychotic use was falling before 2012, before the partnership. And I think that was largely driven by... We didn't test it empirically, but I think it was still driven by the black box warnings. And the 2012 policy did not change that trajectory of antipsychotic decline. Right? That's an aside. It was a little bonus point.

Matt Davis:

It's such a good reminder to our listeners that might be new to research too. Anytime you have a policy change or something, you have an opportunity to look at things before, during, and after.

Lauren Gerlach:

So, can you tell us overall what you found?

Theresa Shireman:

We found that neither the 2012 nor the 2015 policy changes, the National Partnership nor the Star Rating change drove higher rates of exclusionary diagnosis. The baseline rate before 2012 was 2.2%, and it never exceeded 2.9% after that, even after the measure was made publicly available in 2015.

We did split up the sample into some different subgroups. We looked at for-profit nursing homes versus not-for-profit nursing homes, facilities that had a lot more Medicaid recipients, which is a marker, accrued marker of what we call low-resource facilities. And there were differences between those lines, between for-profit, not-for-profit, for high Medicaid versus low Medicaid. There were differences in the rates, but they stayed relatively flat over the entire period of time. So, and we also looked a little bit by differences by race and ethnicity. They bounced around a lot, but at no time, at no time did any of these rates ever exceed 4% for any of these subgroups.

And think about that for a minute. Less than 5% of new admitted, newly admitted or newly long-staying nursing home residents ever picked up an exclusionary diagnosis. And again, this is a matter of perspective. The vast majority of these dementia residents are not getting this diagnosis. And when you read the press articles, it's not how when you read the discussions on some of the peer-reviewed publication, that's not the message that they're sending.

Lauren Gerlach:

So, were you surprised by the findings based on what you've seen published in other work or what some of these kind of other reports were?

Theresa Shireman:

No, I wasn't terribly surprised, because I think that reports, especially public reports, especially press reports are designed to excite, to exaggerate, to call attention to something. And in my opinion, most nursing homes are really trying to appropriately manage their patients. As in any field, there are a few, what we would call bad actors, but the vast majority of nursing homes are really trying to take care of people and respect them and treat them with dignity. And I have no doubt that there are some places where they are just so poorly resourced, that they are so poorly staffed, so poorly funded that they have to go down this pathway, but it is the exception, not the rule.

So on a large scale, when we're looking nationally as we did, when we're looking at all kinds of nursing homes all over the place, I didn't expect it. I didn't think this was going to be a big problem.

Matt Davis:

It makes me wonder, in terms of the Star Rating system, which people talk a lot about, and I guess policy changes and all that. I mean, I could imagine the administrator and people running these organizations are very aware of it, but I wonder how much that trickles down to people on the floor. You know what I mean? I don't know.

Theresa Shireman:

You mean the worker bees in the-

Matt Davis:

Yeah. Are they even aware of the way they're being judged in these public... I mean, are they aware of the public reporting stuff and the guidelines and the Star Ratings and all that?

Theresa Shireman:

That's a really good question. Matt, I actually don't know what frontline staff know. I think they will get signals from the administrators of quality measures in general, not speaking specifically about antipsychotics. But quality measures in general, your average CNA may know something about it. But the CNA is involved in antipsychotic choice insofar as they go to the supervisor and say, "This patient keeps hitting me," or, "This patient is hurting this resident." But the prescribing decision has to elevate to a physician or a nurse practitioner, but it's got to elevate to somebody who has prescribing authority. And so, I'm not sure how much those front end... Is it like 70 to 80% of staffing in a nursing home is a CNA? When I was a CNA, I wouldn't have known what those quality measures were, and there weren't as many back then as there are now. And I think that it's really more, does the facility leadership lean into the medical director and into the prescribing physicians and how do they make that known?

Lauren Gerlach:

I would say from the prescriber side, at least anecdotally from what I hear from friends, colleagues who are working in those settings, that there is some pressure that if they're going to initiate a medication, they're wanting a lot of documentation, which there always should be good justification of why we're choosing agents that potentially have harm. But sometimes people are being maybe encouraged to think about other alternatives, whether those are other alternative medication classes or to clarify, do they really have a diagnosis that could support use? And so, I think there is a lot of encouragement and sometimes pressure to think about alternative options. So at least from the prescribing side, my sense is people are feeling that, but probably a lot of variation across facilities too.

Theresa Shireman:

Yeah. Again, I'll go back to my mother who was put on risperidone and she put on 25, 30 pounds, easily, and became non-ambulatory. That's a huge burden on the staff. That is a huge burden on your nursing staff and certified nurses aid that now I got to get this person up and get them dressed and feed them. And so, it's not a winning situation for the nursing home staff to put people through that. And she was on risperidone. Her aggressive behavior was that she called out, she was vocal. She wasn't hurting anybody. She just was loud, right? And in my opinion, they made it much harder on themselves by putting her in that situation. So, I just think that it has to be a careful balancing of incentives and a careful appreciation of the harms and the benefits of any of them.

Matt Davis:

So back to your principle finding, I mean, should we be reassured by what you found in your study?

Theresa Shireman:

Yeah, yeah. I think you should. I think you should say, "We've looked under this rack and there are bigger issues that need to be dealt with." That nursing homes, again, in my opinion, nursing homes are... In our care for older adults in these institutional settings, there are a lot of other things that are more important for patient dignity and for quality of life. I am terrified to go into a nursing home because I don't think I'm going to get treated very well. Right? And so yeah, I think we should stop beating this drum.

I think CMS is doing some things now where they're trying to look at facilities that seem to be consistent outliers, that consistently have bad reports. And yeah, should somebody go in and talk to those facilities? Should somebody go in there and figure out what they need? Because it's a small number of them. There was a recent CMS report that called out, I think 40, they wrote a, I think it was an OIG report that said, "Here's 40 cases of nursing homes that are drugging people. Right? They're inappropriately using antipsychotics." And in that year, there were, what, 79,000 incident reports from the surveyors. And they pull out 40, a lousy 40 reports to say antipsychotics are a problem. I'm like, you're looking at the wrong stuff. I mean, how many facilities is that? Okay? There's only 1,300 F tags that are medication related in a given year. I mean, if you really want to... But we can measure it. It's measurable. It's got good science behind it that says it's bad to do this stuff. Right?

So, I think there's a lot of other bigger fish to fry that would make the quality of life in a nursing home for the staff and for the residents much better than just going after antipsychotic use.

Lauren Gerlach:

I guess to follow up with that, as someone who's heavily invested in this space, what do you think some of those might be? What are some of the kind of levers and things that we could move to improve the care that patients are receiving?

Theresa Shireman:

Yeah. So, I think it has to be... It's a high personal contact place. Right? And you can't automate this. We can't AI our way out of care. These are human beings, just like our children. Raising a child is a full-time job, right? It takes a lot of commitment. And I think we have to, just like we undervalue childcare, I think we significantly undervalue care of older adults. And these are people who have contributed heavily to where we are as a nation, as a society, and they have earned their due to be treated with respect. And it takes a, let's quit worrying about profit and let's think about what kind of space would you, if you're a nursing home owner, what kind of space would you want to live in? Right?

I think every member of Congress should spend a night in a nursing home. Some probably already are. But really, they need to be in this space. If they're going to make decisions about what should be done, they need to be in this space and understand it. And the economic incentives are not there. Medicare doesn't pay for long-term nursing home care. You have to go poor to get on Medicaid. We've just sucked resources away from that field, and resources that are really necessary to provide a higher level, appropriate level of care, in my opinion.

Matt Davis:

The comedian, John Stewart, not to get into politics, but he often calls the Senate an assisted living facility.

Theresa Shireman:

Yeah. The average age is up there. And I respect people who have been career politicians, but they should want something better than what we're giving. And there are some wonderful nursing homes. There are large numbers of nursing homes that don't use antipsychotics at all. I mean, so I've heard. There are places where you really want to go, and I think but what we see repeatedly is our Star Ratings are able to call out facilities that are having trouble. So, why don't we invest in them? Why do we punish them? Why don't we invest in them? Why don't we find a way? And if that means having Medicare start paying for long-term care alongside Medicaid or doing some other kind of financial modeling, we could elevate the bottom. We really should elevate the bottom is what we should do rather than penalize the bottom. We should help figure out what they need to do.

Lauren Gerlach:

Definitely an important shift in perspective and how to best improve care.

Linked to the article, there was a great editorial by Joseph Ouslander that really raised the broader question of some of the things that we've talked about, about whether antipsychotics in nursing homes are best understood as a chemical restraint or in some cases as essential tools. And I think there's a tension there that you've brought up. And just thinking about in general, your thoughts about how facilities should best balance medication safety with the reality that some residents really experience severe distress, agitation, or risk of harm for which these medications can be useful. How do you think about that nuance? And if you were talking to policymakers or other folks, how would you help convey that?

Theresa Shireman:

Yeah. I agreed with us under comment that, it depends. The use of a... So, we use any medication. Any medication that is prescribed is implicitly, let me say it implicitly, a balance of risk and benefits. Right? And it's just that some classes of drugs have greater risk, but they also, in some cases, have tremendous benefits. And again, I said earlier in the program that antipsychotics have tremendous benefits. They have really changed people's lives, right? And they can be very important at a moment when you have a nursing home resident who is violent, who is violent towards others, who is violent towards themselves. Right? That harm is real, and I get it. And if you need to give them an injection of something to calm them down and get them under control, and that may take multiple times, and that may take multiple days. And they may need to be on that drug for a while, because the risks are so high if you don't.

But you also need to reconsider and reassess and come back and say, "Okay, can we let up on the gas pedal? Can we dial the dose back? Can we find an alternative approach to try to keep this person calm?" I've got a colleague who does music therapy and puts iPod shuffles on people's heads, or she wants to try ambient music. Are there other ways can we change the lighting in the facility? We've got to keep... I would rather spend all this money that we're doing to study antipsychotic policy and think about, can we invest that money in doing something more positive for nursing homes and create a better space there? So, and I also think there has to be a better team approach and the shared decision making. And that's another thing that CMS is, advanced policy and antipsychotics is they want to see more team decision making.

My family was locked out of the room. I mean, we weren't locked out of the room, so we went to the care plan meetings and we said, "Take her off the risperidone." And they said, "We can't do it. She starts hollering." And I'm like, "Can't we talk about this?" And they said, "No, no, no, we can't talk about it." And so you have your frontline staff, you have the CNAs who really, sometimes they know people really well. They know what calms somebody down better than anybody else. You've got nurses who have great experience in the facility, you have some prescribers who are just really masterful at knowing how to manage people. You get these people in the room with the family. I think sometimes family ask for these drugs, sometimes families want these drugs. We can't always assume that each of the players that we're talking to has a motivation to go one way. But if you can put them together and get them to talk and talk to each other, then shared decision making could help a lot more.

So yeah, we're not going to get away from having to chemically restrain people at times. But what we'd really like to do is to find ways of engaging people to make them less combative and less disastrous.

Matt Davis:

That's nice to hear about the shared decision making, because I had that thought when you were talking about antipsychotic use and the importance of like people being involved in that decision. That's like, that should be the measure that we're doing, not just a simple numerator, denominator, kind of thing.

Theresa Shireman:

Yeah, yeah. I actually would love to do a study of shared decision making, but it's hard to get into those spaces too.

Lauren Gerlach:

So, what do you think is next for you and your team? What other things are you currently working on?

Theresa Shireman:

So in response to that OIG report, I've got a graduate student who has pulled down all of the surveyor responses, the nursing home surveys, for about six years. And I want to go into that and say, "All right, let's see how often antipsychotics show up, which agents are showing up under F tags." So we're pulling out the F tags, which are the medication F tags. Right? And to really dig into, the easy question is, are these 40 cases representative of what's going on? How big of a deal are they?

But I also think that there are places... I think there's a bunch of medication tags that are kind of silly, that really don't have a big impact on nursing home care. And so, we're going to try to use natural language processing to get through some of the coding of the surveyor reports of bad things that are happening in nursing homes in the context of medication and sort out. And then maybe think about, okay, are there facilities that regularly show up on this list? Are there facilities that are... and what are some of the characteristics of those facilities? Do we have a logical target? Are these things that are perennial or are they things that are really just episodic? And if they're episodic, like once a facility gets cited every five years for it, I don't really want to spend a lot of time and energy on going after that facility. So, that's one of the things that we're looking at is, let's dig into those surveyor reports.

It is a little bit scary to think about surveyors, nursing home surveys right now, because they are not being done on a regular basis. Most nursing homes are only being surveyed about every 18 months, they're supposed to be surveyed every year. There's not a workforce to do those surveys. There's a lot of problems of that. And there are private companies that will do the surveys for you that you can hire. A state can hire a private company to do it, but it costs, I think the equivalent of three or four annual surveys to do one year. So I mean, it's crazy. So I'm walking in a new tunnel of nursing home quality.

Lauren Gerlach:

And is there anything else that we haven't covered that you think is important for either clinicians, researchers, or policymakers to understand?

Theresa Shireman:

I think the basic idea that we should try to come to therapeutic decision making for people that's going to maximize the benefits, and reassess when the risks come too high. I think trying to get more information about a person to help figure out what makes them tick and how they're going to behave, especially in an institutionalized setting. Recognizing though that sometimes people have been "abandoned" in a nursing home and you don't have a lot of family contact for them. And I'm also leaning really hard anymore against some of these publicly facing quality measures that force facilities to make choices about what they're going to invest in. And a facility may not need to invest in antipsychotic management because it's not a problem for them, but because it's a quality measure, they have to keep an eye on it. And I think we tie the hands of some of our provider organizations and facilities when we give them a set of quality measures that are, these are the things that are most important. And I'm not sure that those are always the most important and certainly not necessarily the most important for that facility, so.

Lauren Gerlach:

Theresa, thank you so much for joining us today, and thank you to all of you who listened in. We'll be sure to include a link to the study with this episode.

Matt Davis:

If you enjoyed our discussion today, please consider subscribing to our podcast. Other episodes can be found on Apple Podcasts, Spotify, and SoundCloud, as well as directly from us at capra.med.umich.edu, where a full transcript of this episode is also available. On our website, you'll also find links to other resources we've created specifically for dementia research.

Music and engineering for this podcast was provided by Dan Langa. More information is available at www.danlanga.com. Minding Memory is part of the Michigan Medicine Podcast Network. Find more shows at michiganmedicine.org/podcasts. Support for this podcast comes from the National Institute on Aging at the National Institutes of Health, as well as the Institute for Healthcare Policy and Innovation at the University of Michigan.

The views expressed in this podcast do not necessarily represent the views of the NIH or the University of Michigan. Thanks for joining us, and we'll be back soon.