Frequently Asked Questions

Frequently Asked Questions

What drugs are tracked by CMS?

CMS tracks the use of a variety of psychoactive drugs including antipsychotics, hypnotics, anti-depressants, and anti-anxiety medications.

What are antipsychotics?
Antipsychotics are a group of drugs used to manage psychosis including delusions and hallucinations.  An antipsychotic drug is a chemical substance that crosses the blood–brain barrier and acts primarily upon the central nervous system where it affects brain function, resulting in changes in perception, mood, consciousness, cognition, and behavior. 

Atypical antipsychotic medications also called “novel” antipsychotics have different chemical characteristics from the older, conventional drugs used to treat psychosis.  Atypical or novel medications are far less likely to side effects.   In addition, atypical antipsychotics may be effective in some cases where there is a resistance to older drugs.

Drugs in this group contain Clozapine ( Clozaril), Risperidone (Risperdal), Olanzapine (Zyprexa), Quetiapine (Seroquel), Ziprasidone (Geodon), Aripiprazole (Abilify), Paliperidone (Invega), Iloperidone (Fanapt), Asenapine (Saphris), and Lurasidone (Latuda).

Traditional antipsychotics include Haloperidol (Haldol), Chlorpromazine (Thorazine), Fluphenazine (Prolixin), Thiothixene (Navane) and others.

Black box warning:  The Food and Drug Administration has issued a warning for all antipsychotic medications after studies revealed an increased risk of serious cardiovascular and cerebrovascular events including an increased risk of death.

What does federal law say about the use of antipsychotics?
CMS regulates the use of medication.  According to its State Operations Manual:

Proper medical selection in prescribing (including dose, duration, and type of medication(s) may help stabilize or improve a resident’s outcome, quality of life and functional capacity. Any medication or combination of medication – or the use of a medication without adequate indications, in excessive dose, for an excessive duration, or without adequate monitoring – may increase the risk of a broad range of adverse consequences such as medication interactions, depression, confusion, immobility, falls, and related hip fractures. 

What does state law say about the use of antipsychotics?
Title 22 of the California code of regulations Section 72528(c) states:

Before initiating the administration of psychotherapeutic drugs… facility staff shall verify that the patient's health record contains documentation that the patient has given informed consent to the proposed treatment or procedure.

What is informed consent?
Informed consent requires the attending physicians to explain the elements of the residents’ care plan, including the use of medications, and obtain consent from the resident or a designated family member before any treatment is administered. 

In the case of an emergency, what if a skilled nursing facility resident lacks capacity to make health care decisions and is not under a conservatorship?
An interdisciplinary team may make health care decisions on the patient’s behalf if the patient has no:

  • Family member who is available and willing to make health care decisions, and

  • Conservator of the person, and

  • Other person with legal authority to make health care decisions on his or her behalf.

Why do some facilities have unusually high levels of residents on antipsychotic medication?
There are a number of skilled nursing facilities in California with special treatment programs (STPs).

These facilities provide 24 hour care to residents with a primary psychiatric diagnosis who may also possess a co-existing medical conditions or to residents with 24 hour medical needs who have secondary behavioral conditions.

These facilities are generally locked units, licensed by the California Department of Public Health and certified by the California Department of Mental Health.  Physicians and psychiatrists often appropriately prescribe antipsychotic medication to patients with diagnosed mental disorders including delusions, hallucinations and schizophrenia.  Special treatment programs also provide individualized plans of care, including behavior modification and special activities to help residents maintain quality of life and the highest level of functioning.  

The federal government keeps track of the number of residents receiving anti-psychotic medication and posts updates on Nursing Home Compare However, this information is not risk-adjusted to include all the major psychiatric illnesses in which these medications are commonly indicated and helpful such as bi-polar disorder, depression with psychotic features, and schizo-affective disorder.

In other words, the newest version of Nursing Home Compare only excludes residents with Schizophrenia, Tourette’s syndrome, and Huntington’s disease and does not exclude residents with other psychiatric disorders.  As a result, STPs often report a higher number of residents on antipsychotic medication because many residents suffer from psychiatric conditions, where antipsychotic medication is appropriate.

What does the Alzheimer’s Association say about the use of antipsychotic medication?
”Non-pharmacologic interventions should be used first to address behavioral and psychiatric symptoms in those with dementia. The research evidence as well as governmental warnings and guidance governing use of antipsychotics show that individuals with dementia should only use these medications when their behavioral symptoms are: due to mania or psychosis; or the symptoms present a danger to the resident or others; or the resident is experiencing inconsolable or persistent distress, a significant decline in function, or substantial difficulty receiving needed care. These medications should not be used to sedate or restrain persons with dementia. The minimum dosage should be used for the minimum amount of time possible. Adverse side effects require careful monitoring. If nursing facilities, medical directors, and their staff follow current governmental guidance on use of antipsychotics, problems associated with use of these medications can be minimized.”