Dementia Care, Antipsychotics, and the New Survey Process

Dementia is increasingly prevalent among nursing facility residents, and facility leaders have been under a lot of pressure to specialize care to meet the growing need. Every 66 seconds, someone in the United States develops Alzheimer's dementia, which is forecasted to increase to every 33 seconds by mid-century. Currently, 68% of nursing facility residents 85 and older have cognitive impairment from Alzheimer’s or a related disorder.

The National Partnership to Improve Dementia Care1—which includes federal and state agencies, nursing facilities, other providers, advocacy groups, and caregivers—is a 2012 initiative by the Centers for Medicare & Medicaid Services (CMS) to promote comprehensive dementia care and therapeutic interventions for nursing facility residents with dementia-related behaviors. Goals of the initiative include a person-centered focus on care and reducing unnecessary antipsychotic medication use. In October 2017, CMS announced2 that the Partnership’s initial goal—reducing antipsychotic use among long-stay nursing home residents by 30% by the end of 2016—had been reached. An ambitious new national goal has now been set for improved dementia care: a 15% reduction in antipsychotic medication use by the end of 2019 for long-stay residents in those facilities with currently limited reduction rates.

How the new goal came about

One trigger for the nationwide dementia effort was a May 2011 Office of Inspector General (OIG) report3 about use of atypical antipsychotic drugs among elderly nursing facility residents, especially when prescribed for off-label conditions (i.e., other than schizophrenia and/or bipolar disorder). A summary of the Medicare claims reviewed for atypical antipsychotic drug use for January through June 2007 showed sobering statistics:

  • 14% of the 2.1 million elderly nursing home residents had at least one claim for these drugs.

  • 83% of claims were associated with atypical antipsychotic drugs used for off-label conditions.

  • 88% were used in the presence of the condition specified by the FDA boxed warning.

  • 51% of claims did not meet Medicare’s medically accepted conditions, amounting to $116 million.

  • 22% of the atypical antipsychotic drugs associated with the sampled claims did not comply with CMS standards regarding unnecessary drugs in nursing homes, amounting to $63 million.

OIG’s report further stated that although the FDA had approved some atypical antipsychotic medications for schizophrenia and/or bipolar disorder, the side effects had been shown to increase the risk of death in the elderly (leading to black-box warnings).

Survey data also found that the Unnecessary Drug requirement of participation (F329, renumbered F757 in November 2017) was typically among the 10 most frequently cited deficiencies nationwide.

The evidence of dismal care led to increased scrutiny. The 2014 Focused Dementia Care Survey pilot study tested surveyors’ knowledge of dementia care and their ability to evaluate its quality. A 2015 expansion of the pilot project further examined the process of prescribing antipsychotic medications and facilities’ compliance with the federal dementia-care regulations. This helped CMS surveyors determine deficient practices and identify successful dementia programs.

In early 2015 CMS added the two publicly reported Quality Measures of antipsychotic use (one for long stay and one for short stay); these are now used to calculate each nursing facility’s Five-Star rating. Public awareness of the Five-Star Rating System has increased immensely over the last several years, leading residents, preferred providers, and consumers to question a facility’s ranking and underscoring the need for nursing administration to be able to discuss and sometimes even defend those scores.

Resources to help meet tough goals

Dementia care management is mandatory, and facility staff must be prepared. CMS has made available to all nursing facilities the revised materials used in the Dementia Focused Surveys. CMS’s intent is for nursing facility leaders to use these tools to assess their own practices in providing resident care. Other resources include the Hand in Hand Training Series, Focused Dementia Survey Worksheets, and new survey Critical Element Pathways for Dementia Care and Unnecessary Medications. In addition, CMS just released Resident-Specific and Facility-Specific Questions for 2018.4,5

How to get started at improving your facility’s dementia care

The new survey process starts with the Matrix for Providers, which requires the provider to divulge a list of residents to the surveyors, specifically noting diagnoses of Alzheimer’s disease or dementia of any type, as well as residents receiving any of the newly defined psychotropic medications (any drug that affects brain activities associated with mental processes and behaviors), such as antipsychotics, antidepressants, antianxieties, and hypnotics.

Gather the list of residents compiled on the Matrix, identify a resident with dementia, and reach for the Critical Element Pathway for Dementia Care6:

  • Can you observe appropriate dementia care treatment and services being provided?

  • Is the care plan person-centered; reflective of the resident’s goals; and written to maximize dignity, autonomy, privacy, socialization, independence, and choice?

  • What non-pharmacological interventions are being used to maintain the resident’s well-being?

  • How do staff modify the environment to accommodate the resident’s care needs? (Think about noise levels and adequate lighting—bright in the daytime and dark at night.)

  • Ask a member of the interdisciplinary team what the facility’s dementia care guidelines and protocols are.

  • Ask about the dementia management training the staff member received.

  • Can the staff member identify and assess behavioral expressions or indications of distress with enough specific detail to identify the cause?

  • Was the resident and/or family/representative involved in care plan development?

In addition, facility leaders should ensure that a staff member has been designated as the champion for their dementia care program. And the revised Appendix PP definition of psychotropic drugs should serve as a reminder to audit your Nursing Home Compare measure for use of an antianxiety or hypnotic medication and the surveyor measure for the prevalence of use of those drugs, which will be a focus for the surveyors. Consider whether reductions were attempted, what monitoring took place during the reduction, and whether the residents triggered accurately.

For successful surveys, dementia care must be a focus. The Critical Element Pathways are ready-made audit tools. Use them to identify the needs, strengths, and weaknesses of your dementia care program and develop an action plan and/or a Performance Improvement Project. The revised requirements of participation effective November 28, 2016, mention dementia care and cognitive impairment over 150 times. The rules and tools are there, but our eyes and hearts must be open to establishing the dementia care program that welcomes the elderly with dementia and provides the care this golden generation deserves.



  1. Centers for Medicare & Medicaid Services. National Partnership to Improve Dementia Care in Nursing Homes.

  2. Centers for Medicare & Medicaid Services. Data show National Partnership to Improve Dementia Care achieves goals to reduce unnecessary antipsychotic medications in nursing homes. October 2, 2017.

  3. Office of Inspector General. Medicare Atypical Antipsychotic Drug Claims for Elderly Nursing Home Residents (OEI-07-08-00150). May 2011.

  4. Centers for Medicare & Medicaid Services. Focused Dementia Care Survey: Resident-Specific Questions.

  5. Centers for Medicare & Medicaid Services. Focused Dementia Care Survey: Facility-Specific Questions.

  6. Centers for Medicare & Medicaid Services. CMS-20133 (5/2017), Dementia Care Critical Element Pathway.

Additional Resources

National Nursing Home Quality Improvement Campaign. 

State Dementia Care Coalition Best-Practice Strategies, July/August 2017.


Topics: Alzheimer's/Dementia , Clinical Leadership , Uncategorized