Can personalized playlists help care organizations to reduce reliance on antipsychotics to manage behavioral and psychological symptoms of dementia? Research is ongoing in Wisconsin to answer that very question.
Two years ago, Wisconsin’s Department of Health Services (DHS) introduced MUSIC & MEMORY® in 100 nursing homes across the state. In a second phase in 2014, DHS expanded the program to bring Music & Memory to an additional 150 nursing homes.
Wisconsin initiated the personalized music program as a non-pharmacological intervention strategy for nursing homes that complements the CMS Partnership effort to reduce use of antipsychotics for residents diagnosed with dementia.
Before the state’s Music & Memory Program, across all nursing homes in the second quarter of 2013, 17.4 percent of residents were taking antipsychotics; a year later, use had declined to 14.6 percent. In fall 2014, Wisconsin moved from tenth to fourth place among all 50 states in the national initiative to reduce use of antipsychotic drugs in nursing homes.
Researchers at the University of Wisconsin, Milwaukee, are currently completing a study of whether the reduction can be attributed to Music & Memory. More specifically, they are seeking to determine the precise impact of personalized music as a viable alternative to these medications, which may often cause significant, undesirable side effects for people with Alzheimer’s and other forms of dementia.
A Framework for Planning Antipsychotic Dosage Reduction
While definitive research is still underway, Douglas Englebert, DHS’s pharmacy practice consultant, has been encouraged by positive observations from nursing home professionals about the benefits of personalized music as an alternative to antipsychotics. Those anecdotal reports have prompted Englebert to respond to the next set of pressing questions from the field: When is it appropriate to taper residents off their antipsychotics, and what is the best method?
Basically, he says, it depends on the individual. There are no definitive protocols for tapering off antipsychotics offered by pharmaceutical companies or approved by the Food and Drug Administration. However, two fundamentals are essential to developing any plan:
1) Define why the antipsychotic is being administered and how success should be measured.
“Up front, before the drug is first administered, you need to have a good discussion about whether the medication is going to be effective,” says Englebert. “That means you have to define what success is and when to expect it to occur. And if it doesn’t work, then you go to dose reduction.”
Wisconsin requires written, informed consent for treatment with antipsychotics in nursing homes. But use of these medications doesn’t always originate when someone moves into a long-term care setting. Individuals may already be on the drugs when they arrive, to manage behaviors while they still lived at home or in assisted living. Or the drugs may have been prescribed during a hospital stay.
For example, Englebert says, someone may be hospitalized for a surgical procedure and put on antipsychotics to manage hallucinations from anesthesia. But unless a physician writes a stop order post-discharge, a medication that was only intended for use over two or three weeks may still be part of the individual’s regimen six months later.
“If someone is admitted to a nursing home on antipsychotics, you need to immediately evaluate the need to use the medication,” he says. “We’re focused on training and education about that. The antipsychotic may have been completely appropriate while the person was hospitalized, but not for long-term use.”
A clearly defined reason for administering the antipsychotic, as well as agreed-upon measures of success, are essential for proper assessment of drug effectiveness and informed decisions about alternative treatments. For any dosage tapering protocol, it’s also very important to be able to distinguish among side effects, withdrawal symptoms and the behaviors that originally triggered use of the drug.
“With these medications, dose reductions can lead to side effects or adverse effects becoming more pronounced,” says Englebert. “The person may experience shaking and other similar symptoms that are side effects—which should not to be confused with a return to the original behavior.”
2) When it’s deemed appropriate to discontinue antipsychotics, reduce dosage slowly.
Because each individual’s biology and circumstances are unique—and because many factors affect the decision to taper off antipsychotics—Englebert promotes a go-slow approach to dosage reduction.
He’s seen successful results from a variety of protocols, ranging from a 25 percent dosage reduction each week for four weeks (an approach promoted in the UK, which has made antipsychotic reduction for Alzheimer’s patients a high priority) to a 5 percent dosage reduction weekly or 10 percent reduction biweekly.
Managing side effects of dosage reduction is only part of the mix. Social or environmental factors also play a significant role. In fact, Englebert says, successful antipsychotic reduction is as much a process of winning the trust of family and staff as it is managing the individual’s physiological and psychological response to the change in medication.
“Say we have five residents on antipsychotics in one facility,” he says. “They’re all making progress on non-medication alternative treatments, but you can’t reduce all of their medications at once. Staff may feel they do not have the staffing to manage behaviors should they reoccur. Or the families may not be open to it. Maybe they’ve tried in the past and failed, and they’re afraid of trying again.”
He suggests starting with one individual whose family or staff is receptive to the idea. Once that person successfully tapers off the antipsychotic, another family may become open. In addition, he says, it’s important to consider staffing levels when scheduling a dosage reduction. Pick a time when extra staff are available, maybe when there are extra activities scheduled, to try the first dose reduction, so that enough help is around if the individual needs support.
Dosage reduction plans also depend on the specific medication, how the dose can be manipulated, and basics such as whether the tablet can be cut. And, of course, any reduction in antipsychotics depends on the successful adoption of a non-medication alternative, such as personalized music playlists.
Leadership is Key to a Reduction in Antipsychotic Use
Variation in rate of antipsychotic use across care organizations depends on many factors—nature of the resident population, culture of care, staff attitudes, preferences of attending physicians. But the most important factor leading to successful antipsychotic reduction is leadership.
“The facilities with the greatest success have leaders that have pushed for it,” says Englebert. “When those leaders leave, that push can leave with them. We want to be sure to build this awareness into the culture of all our facilities, so our success can continue.
“Our goal is for each person to have the best quality of life. If the antipsychotic isn’t working, get rid of it.”
For more information, see Wisconsin DHS’s Antipsychotic Medication Reduction Resource.
Founded in 2010, MUSIC & MEMORY® is a non-profit organization that brings personalized music into the lives of the elderly or infirm through digital music technology, vastly improving quality of life.