FAQ: Ecumen Awakenings Initiative to Reduce Antipsychotic Drugs Among Patients with Alzheimer's
What is Awakenings?
Awakenings is an innovative, three-year, Ecumen initiative that’s trying a new way to treat older adults who have Alzheimer’s and dementia. It emphasizes human relationships, non-drug therapies, and teamwork rather than commonly prescribed antipsychotic or other psychotropic drugs, which can actually reduce quality of life.
Concerned about the number of new admissions who were being treated with antipsychotic drugs for dementia, Ecumen staff decided to try a new model of “relationship” care in one of its nursing homes. In 2009, we piloted what has become known as “Awakenings” in Ecumen Scenic Shores Nursing Home (previously called Sunrise Home) in Two Harbors, Minnesota. Within six months, the home eliminated the use of antipsychotic drugs among all residents, and decreased their use of antidepressants by 30-50%. As a result, many residents were literally “awakened” to a fuller life. What was once a quiet nursing home is now a much more bustling, vital community.
Based on these remarkable results and with support from a $3.8 million grant from the State of Minnesota, we’ve formalized and expanded Awakenings to other Ecumen nursing homes. It’s one more way we can help ensure that life is more active, enjoyable, and dignified for our older adult residents.
What are antipsychotic drugs and why are they used in nursing homes?
Antipsychotic drugs are commonly prescribed to nursing home residents with Alzheimer’s and dementia to control agitation and other behavioral issues. Sometimes they’re referred to as “chemical restraints.” Even though antipsychotics are meant for use with residents diagnosed with mental illness, more than half are prescribed to control dementia-related behaviors where there is no mental illness diagnosis. For some people with dementia, antipsychotics play a helpful role, but for many others they significantly decrease quality of life.
Even though statistics vary from state to state, up to 45% of nursing home residents receive antipsychotic drugs. In Minnesota alone, it’s estimated there are at least 27,000 nursing home residents on such medication. These drugs carry many risks for the elderly. Residents often experience tremors, drowsiness, sluggishness, and impaired mobility that reduce their quality of life. In addition, antipsychotics increase risk for strokes, pneumonia, and serious adverse drug events leading to hospitalization or even death. These drugs carry a Food and Drug Administration black-box warning that elderly patients who use them have an increased risk of death.
The use of antipsychotic drugs has skyrocketed in recent years. Medicaid spends more on this class of drug than any other class—including antibiotics, AIDS drugs, or medicines to treat high blood pressure.
What changed at the nursing home where Awakenings was piloted?
The nursing home’s entire culture changed. Instead of leading with pharmaceutical care—the practice of prescribing drugs—treatment became focused first on relationship care. A collaborative team—a trusted “circle of care”—was established around each resident that included family, the right doctors, and other members from all disciplines. They created an individually tailored alternative care plan, the goal of which was to exhaust every alternative and resource before turning to pharmaceutical remedies.
As residents were weaned off antipsychotics, all staff members became very engaged in doing meaningful activities with residents, regularly taking them on walks, playing games, and exercising. Certified Nursing Assistants assumed a more important care-giving role. More use was made of alternative treatments such as validation therapy, reminiscence therapy, music therapy, aromatherapy, pet therapy, therapeutic touch, spiritual care, and noise reduction in reducing problem behaviors among residents with Alzheimer’s disease or other dementias.
Before the pilot project, the home was relatively quiet: certain residents preferred to stay in bed all day and others sometimes held a far-off, vacant look. Today, it’s not uncommon to see a large group of residents engaged in activity such as playing a rousing game of balloon volleyball in the dining room.
Aren’t there already regulations that prohibit the use of unnecessary medications at nursing homes?
Yes, but keep in mind that regulations are minimum requirements, and are open to interpretation by nursing home staff members. Awakenings goes beyond minimum requirements. For those with Alzheimer’s or dementia, we believe that behavioral interventions should be exhausted before turning to pharmaceutical interventions.
Are antipsychotic drugs always inappropriate for people with dementia and Alzheimer’s?
There’s a place for antipsychotic medications. At Ecumen, rather than taking an all or nothing approach, we’re working to find the right balance. For some people these medications are essential, but for others they're not and have simply become a default. In the Awakenings model, a cross-functional team including the physician, nurses, and family carefully evaluates the situation and tries to find the right mix of care to ensure the resident’s best quality of life. Sometimes that includes drugs, but often it doesn’t.
Has this kind of project ever been done before?
A handful of other nursing homes around the country have undertaken projects using similar strategies. Two years ago, Cobble Hill Medical Center in Brooklyn, N.Y. reduced the use of antipsychotic drugs by about 50%. One key conclusion was that weaning nursing home residents off antipsychotic medications required “a culture change” and getting nurses on board was an important first step. The Lighthouse at Bethany Riverside in La Crosse, Wisconsin said that improving staff-resident relationships was critical to their success at transitioning residents off unnecessary medications.
What’s innovative about Awakenings is its scale. First, as far as we know, there’s never before been such a widespread trial of these alternative practices in this country. Second, we’re retooling the entire approach to care. We’re replacing a fragmented approach often found in healthcare today with a holistic approach centered on the individual. We’re taking practices that have been proven through research and figuring how to apply them in the real world of long-term care. In the process, we’re radically changing the culture of medication use in nursing homes.
How radical is this shift?
Think about our medicine-oriented society, and the challenge of changing the culture in only one location. Ecumen is asking diverse people at 15 nursing homes across Minnesota to work together to move from dependency on medication to more individualized, innovative care. The results could provide much needed guidance for nursing homes across the country in how best to care for elders with dementia.
Where are the other nursing homes located in Minnesota where Awakenings is being introduced?
- Chisago City
- Detroit Lakes
- Grand Rapids
- Lake Park
- North Branch
- Park Rapids
- Pelican Rapids
What will happen at these nursing homes?
Introducing a culture change like Awakenings is a long-term undertaking, but well worth it. It will take three years to completely expand the initiative to the other 14 nursing homes in Minnesota. In order to refocus care on relationships rather than drugs, each of these homes has to undergo a transformation that includes:
- Recruiting and educating local doctors
- Hiring project leaders who are ready and willing to care for residents in new ways
- Informing and fully engaging families
- Retraining all direct care workers, professional staff, and management
- Developing systems and procedures to make sure that new methods of care (exercise, music, activities, brain fitness, etc.) are used instead of or in addition to appropriately prescribed medicines.
Much of this preparatory work has already been undertaken, and early results are promising. Reports are coming in that people who have been wheelchair or bed-ridden are beginning to walk again. Others who have spent a lot of time alone in their rooms are talking again, and rejoining group activities and games.
What happens at the nursing homes when Awakenings is completed?
At the end of three years, if results are as positive as we anticipate, we’re planning for Awakenings to become standard operating procedure. Individualized care will be the new norm. Nurses will no longer call a physician to get orders for psychotropic drugs. This will be a full team decision based on the particular needs of the resident.
Could any nursing home undertake a program like Awakenings?
Definitely. Many nursing homes have made strides in culture changes and providing individualized care. Part of the problem is that there’s so much information available on how to care for people with dementia, it can be overwhelming. The key is getting a nursing home’s leadership staff onboard and then developing a plan. Pick at least one or two things to implement consistently. For example, have a medication policy where starting an antipsychotic medication is a team decision. Provide education on how staff can contribute to behavioral symptoms by the way they approach people and how they talk to them. Teach staff alternate ways to treat behavioral symptoms besides medications and hold them to it.