The Proper Standard for Dementia Care

The Center for Medicare Services (CMS) formally adopted changes to its guidance to federal nursing home surveyors last week. Although the new guidance on dementia care had been previously released via memorandum, the standards are very good and are worth another review.

CMS details a very deliberative and careful process for treating distress in people with dementia.

The use of any approach must be based on a careful, detailed assessment of physical, psychological and behavioral symptoms and underlying causes as well as potential situational or environmental reasons for the behaviors. Caregivers and practitioners are expected to understand or explain the rationale for interventions/approaches, to monitor the effectiveness of those interventions/approaches, and to provide ongoing assessment as to whether they are improving or stabilizing the resident’s status or causing adverse consequences. [emphasis added]

In this context of thoughtful assessment, nursing home staff members should be reluctant to turn to drugging options.

In many situations, medications may not be necessary; staff/practitioners should not automatically assume that medications are an appropriate treatment without a systematic evaluation of the resident . . . . When antipsychotic medications are used without an adequate rationale, or for the sole purpose of limiting or controlling behavior of an unidentified cause, there is little chance that they will be effective, and they commonly cause complications . . . and increased risk of death.

Later, the guidance states “antipsychotic medications are only appropriate for elderly residents in a small minority of circumstances.”

Perhaps most importantly, the guidance says nursing homes that care for people with dementia are violating the federal care standards unless they have:

  1. Obtained details about the person’s behaviors (nature, frequency, severity, and duration) and risks of those behaviors, and discussed potential underlying causes with the care team and (to the extent possible) resident, family or representative;
  2. Excluded potentially remediable (medical, medication-related, psychiatric, physical, functional, psychosocial, emotional, environmental) causes of behaviors and determined if symptoms were severe, distressing or risky enough to adversely affect the safety of residents;
  3. Implemented environmental and other approaches in an attempt to understand and address behavior as a form of communication and modified the environment and daily routines to meet the person’s needs;
  4. Implemented the care plan consistently and communicated across shifts and among caregivers and with the resident or family/representative (to the extent possible); and
  5. Assessed the effects of the approaches, identified benefits and complications in a timely fashion, involved the attending physician and medical director as appropriate, and adjusted treatment accordingly.
The deliberative, non-drugging approach to dementia care required in the new surveyor guidance is long overdue in many of our nation’s nursing homes. Hopefully, the guidance will  help them improve but, as always, the standards will need to be meaningfully enforced to make much of a difference.
You can read the new guidance here under F-tags F-309 and F-329. The new language is in red.
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About achicotel

Anthony Chicotel is a staff attorney for CANHR. His areas of expertise include the rights of long-term care residents, nursing home litigation, health care decision-making, and conservatorships.
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