CGPR: Please tell us about your work.

Dr. Nash: As an internal medicine physician and geriatric psychiatrist, I focus on medically complex older adults with neuropsychiatric and chronic medical conditions.

CGPR: What are some of the challenges of working with patients in nursing homes?

Dr. Nash: The main challenge is that the Centers for Medicare and Medicaid Services (CMS) regulations for using antipsychotics for neuropsychiatric diseases in nursing homes are quite restrictive. They hinder our goals of improving the quality of care and the quality of life for these patients. The CMS rules around gradual dose reductions for psychotropic medications are not evidence based.

CGPR: Can you speak more about that?

Dr. Nash: Absolutely. CMS inappropriately regulates the use of antipsychotic prescriptions and other psychotropic medications. According to CMS regulations and guidelines: “Residents who use psychotropic drugs must receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs” (www.tinyurl.com/4tsje864). CMS regulations, and more importantly the CMS surveyor manual, manifest a misunderstanding that psychotropic medications are only appropriate for very short-term symptom management or in very specific long-term cases. Even if reducing the dose causes someone to decompensate and suffer greatly, it doesn’t count unless it happened within the last two years in a nursing facility. These mandated dosage reductions often lead to the decompensation of people with psychiatric or neuropsychiatric disease. Symptoms can take months or even several years to come back, but even one episode of illness can cause significant suffering, lost relationships, and perhaps eviction. The standard of care for most people with serious mental illness (SMI) is indefinite treatment when they are stable, as lowering doses may lead to decompensation. Note that SMI increases the risk of developing dementia greatly (Richmond-Rakerd LS et al, JAMA Psychiatry 2022;79(4):333–340).

CGPR: Why do you think this disconnect between CMS policy and best treatment practices exists?

Dr. Nash: CMS and others appear to operate on the false assumption that antipsychotics are always used as chemical restraints rather than as evidence-based treatments for symptoms and diseases. Antipsychotics are an effective class of medications for treating psychotic symptoms, such as delusions or paranoia. However, they have many other uses, including managing symptoms of terminal delirium and nausea.

CGPR: Tell us more about the consequences of CMS regulations on antipsychotic usage in nursing homes.

Dr. Nash: These policies lead to poorly controlled symptoms, causing nursing facilities to send residents to the hospital and then refuse to take them back. This indirect eviction causes challenges for residents, as well as hospitals and families. A nursing facility is penalized by the CMS star rating system when they have residents who are treated with antipsychotics for many appropriate indications. This policy overlooks the use of antipsychotic medications for treating major depressive disorder, bipolar disorder (BD), agitation in Alzheimer’s disease (AD), nonpsychotic anxiety, and other diseases and instead focuses on just three conditions: schizophrenia, Tourette’s syndrome, and Huntington’s disease.

CGPR: Given these regulations, what do psychiatrists need to know about nursing home documentation?

Dr. Nash: In clinical notes, it’s crucial to detail diagnoses, current and past symptoms, and treatment plans, including informed consent for medication. Clinicians should be aware of the importance of correct diagnostic history in CMS and Health and Human Services (HHS) investigations into nursing homes’ use of schizophrenia diagnoses. However, HHS only considers the last five years of Medicare, not Medicaid claims. Often, outpatient codes miss chronic conditions like BD or schizophrenia if they’re in remission. Clinicians should therefore ensure records reflect long-term mental health conditions—drawing on various sources (including people who know the person), reviewing records, and obtaining psychiatric state hospital records. Never alter a diagnosis based on pressure from nursing home administration.

CGPR: When anxiety is high among the nursing home staff, how do you make sure residents receive adequate care?

Dr. Nash: Geriatric psychiatrists often advocate for staff training, focusing on education alongside direct care. Staff anxiety may be due to an anxiety disorder, skill set mismatches, burnout, understaffing, or past personal experiences. The basic principles I adhere to include: 1) acknowledging and validating the emotional impact of caring for residents suffering with mental illnesses; 2) educating staff on psychiatric signs and symptoms, their definitions, and the different ways symptoms can present; and 3) teaching staff to recognize and address residents’ emotional and behavioral needs. For example, you can help staff identify psychosis in a resident who looks anxious and fearful because of paranoia. Emotions and behaviors often reveal more than words. Prioritize understanding behavior, then emotional expression, and finally verbal communication. This is the exact opposite of what our brains are hard-wired to do.

CGPR: Agitation in dementia can be challenging for nursing home staff. Can you walk us through your treatment algorithm?

Dr. Nash: In emergencies, address potentially dangerous behaviors with medications. Next, investigate the etiology of agitation, noting that staff might misinterpret anxiety or restlessness as agitation. Consider environmental factors, medication adjustments, or acute illnesses. Use an algorithm, such as the Describe, Investigate, Create, Evaluate (DICE) model or the Antecedent/Behavior/Consequence model, in order to discern etiology and to use best practices for care planning. DICE encourages clinicians to look for underlying causes of agitation. Unlike many algorithms, it directs the use of medications first when behaviors are potentially dangerous but also supports the need for individualized care planning to achieve the best outcomes.

CGPR: And if none of these seem to help?

Dr. Nash: In people with agitation and moderate-severe dementia, or any disorder that impairs their ability to communicate verbally, it is reasonable to presume pain as the underlying cause until proven otherwise. The PAIN-AD scale proves valuable for this assessment (­https://­geriatricpain.org/painad). Note that pushing people away, hitting out, pacing, or screaming are signs of pain on the PAIN-AD. When agitation is mild, environmental modifications and caregiver support are usually the most effective interventions. When agitation is moderate or severe, medications are usually necessary. I might consider acetaminophen, or if their kidneys can tolerate it, a nonsteroidal anti-inflammatory drug. Often, however, a low dose of an opiate is much friendlier for older adults.

CGPR: What comes next in your algorithm after ruling out pain in a person with dementia?

Dr. Nash: If the patient is yelling out or screaming but does not respond to opiates and other pain medications, they may have repetitive impulsive behaviors that include yelling out. That’s a very small number of people. For those individuals, you have to find a place able to tolerate them, where staff use strategies such as music, constant distraction, etc. to calm them down. I next consider whether agitation may be due to psychosis or anxiety.

CGPR: How do you differentiate between the two?

Dr. Nash: If the person is making paranoid statements, or if they appear fearful or angry, I consider psychosis. People usually do not walk up to you and say “I have paranoid delusions,” but rather appear frightened or angry. Dementia medications such as cholinesterase inhibitors and antipsychotics are useful in preventing and treating psychosis, agitation, or aggression in dementia. Anxiety in dementia can manifest as distress when a caregiver is not present, hyperventilation, physical restlessness, or tenseness. This sometimes responds to a cholinesterase inhibitor, or temporarily to caregiver reassurance. Antidepressants and antianxiety medications are less effective in dementia.

CGPR: At what point do you reach for medications after behavioral interventions?

Dr. Nash: A cholinesterase inhibitor is first-line treatment in those with neuropsychiatric symptoms related to AD, vascular dementia, Lewy body dementia (LBD), or Parkinson’s disease dementia (PDD) (Nash M and Swantek S, Current Psychiatry 2018;17(7):21–25). Although certain behavioral interventions can help individuals, their evidence in managing these symptoms is limited (Brasure M et al. Nonpharmacologic Interventions for Agitation and Aggression in Dementia. Comparative Effectiveness Reviews No. 177. Rockville, MD: Agency for Healthcare Research and Quality; 2016). I suggest using functional cognition testing by a trained occupational therapist as a framework for understanding how to best form a care plan and treat agitation in a person living with dementia. When somebody has AD, vascular dementia, LBD, or PDD, I’ve found a rivastigmine patch effective to treat acute agitation and aggression. The patch provides therapeutic blood levels within 24 hours, offering a quicker response than oral donepezil, which typically takes five or more days to start to work.

CGPR: So you start the rivastigmine patch—after that, when do you start another medication?

Dr. Nash: Treatment varies based on the type of dementia and neuropsychiatric symptoms. For AD or vascular dementia with physical aggression, I prescribe antipsychotics immediately. Evidence supports the use of risperidone, aripiprazole, olanzapine, and recently the FDA-approved brexpiprazole (Tampi RR et al, Ther Adv Chronic Dis 2016;7(5):229–245; Lee D et al, JAMA Neurol 2023;80(12):1307–1316). Despite quetiapine’s common use for anxiety or aggression, its use outside of LBD/PDD is not evidence based. Quetiapine functions as an antihistamine and anticholinergic, potentially increasing confusion in older adults. In LBD/PDD, first lower any dopaminergic medications and consider either low-dose quetiapine, clozapine, or pimavanserin. For acute situations, I use the evidence-based PRNs: risperidone (dissolvable tablet), olanzapine (available as an intramuscular shot, dissolvable tablets, and regular tablets), aripiprazole (available as an oral tablet), and brexpiprazole. If symptoms recur, then regular antipsychotics are needed. I recommend continuing the antipsychotic for the first year, possibly indefinitely, depending on the severity of the aggression. If people respond to an antipsychotic with symptomatic improvement, there is every reason to believe that symptoms will recur if the medication is stopped (Devanand DP et al, N Engl J Med 2012;367(16):1497–1507).

CGPR: Do you remove the patch after you start another medication?

Dr. Nash: I either continue the patch or I switch to an oral cholinesterase inhibitor. I recommend using cholinesterase ­inhibitors and memantine as the primary treatment for neuropsychiatric symptoms in patients with AD, ­vascular ­dementia, and LBD/PDD. Severe agitation in advanced dementia often indicates terminal delirium, hence the effectiveness of ­antipsychotics. Haloperidol (Haldol) is a regularly scheduled and PRN medication in hospice because terminal delirium is nearly universal. The Mini Suffering State Exam is an excellent tool for assessing suffering and life expectancy in advanced dementia (Adunsky A et al, Am J Hosp Palliat Care 2007;24(6):493–498). (Editor’s note: For more on end-of-life care, see CGPR Oct/Nov/Dec 2023.)

CGPR: Is your algorithm the same when psychosis is the cause of agitation?

Dr. Nash: For agitation not improved by cholinesterase inhibitors and memantine, consider olanzapine or risperidone in those with AD or vascular dementia, followed by aripiprazole or brexpiprazole. For LBD/PDD with psychosis, reduce dopaminergic medications first (eg, carbidopa/levodopa); if ineffective, consider adding quetiapine, clozapine, or pimavanserin (Reus VI et al, Focus (Am Psychiatr Publ) 2017;15(1):81–84; Lee et al, 2023). Rarely, after failing multiple other agents, valproate may be needed, but it must be used cautiously, as it is associated with increased brain atrophy (Fleisher AS et al, Neurology 2011;77(13):1263–1271). Antipsychotics are also the most evidence-based treatment for agitation due to frontotemporal dementia (Carrarini C et al, Front Neurol 2021;12:644317). Although the FDA warning notes an increased risk of death in patients with dementia, this is correlative, not causative. Dementia’s progressive nature makes psychosis, agitation, and aggression common during later stages. There is a very small amount of evidence supporting the use of selective serotonin reuptake inhibitors for neuropsychiatric symptoms of dementia, though most of this evidence has been from a single group (Chen K et al, Front Aging Neurosci 2023;15:1103039). I consider antidepressants a fifth-line option if everything else has failed.

CGPR: What if you have determined that anxiety is the root of the agitation?

Dr. Nash: I avoid benzodiazepines in those with dementia because they can cause disinhibition and worsened behaviors. If a person has AD, vascular dementia, or LBD/PDD, I start with cholinesterase inhibitors and memantine. If symptoms persist and suffering is high, I consider a low-dose antipsychotic. I use the on-off-on method: Start at a therapeutic dose, continue if effective for weeks or months depending on severity, then pause to assess. If symptoms recur and again respond to the medication, it’s reasonable to maintain the medication indefinitely due to dementia’s progressive nature. You can assess baseline neuropsychiatric symptoms using tools like the Neuropsychiatric Inventory Questionnaire (NPI-Q or NPI-C), which helps teach caregivers terms like “delusion.”

CGPR: Tell us about other common medication considerations in nursing homes.

Dr. Nash: There is minimal evidence for using cholinesterase inhibitors as cognitive enhancers beyond very early disease. However, there is a notable evidence base for using dementia-specific medications for neuropsychiatric symptoms of AD, vascular dementia, and LBD/PDD (Schmidt R et al, Eur J Neurol 2015;22(6):889–898; d’Angremont E et al, JAMA Neurol 2023;80(8):813–823). Memantine helps with appetite and sleep. I prioritize eliminating unnecessary and potentially harmful drugs that will not help a person after calculating life expectancy. I also adjust blood pressure medicines to be more permissive of mild hypertension, which helps perfuse the brain. Medications like statins are not beneficial if life expectancy is less than five years.

CGPR: When do you consider tapering off cholinesterase inhibitors and memantine?

Dr. Nash: Dementia medications delay and treat neuropsychiatric symptoms, so I consider their use indefinitely in patients who experienced benefit and did not develop significant side effects. I don’t lower doses if patients have had severe or moderate symptoms, especially if they have had an ED visit or hospitalization due to neuropsychiatric symptoms. If they have not had neuropsychiatric symptoms, I try to reduce pill burden and polypharmacy, especially medications not targeting neuropsychiatric symptoms and thus quality of life. I might gradually lower the cholinesterase inhibitor or memantine dose by 20%–25% and monitor for two to four months. Tapering should extend over months, longer than one might initially think, to ensure better outcomes. This allows for time for breakthrough symptoms to begin to emerge, and a dose reduction can be reversed.

CGPR: Thank you for your time, Dr. Nash.