Jan 6, 2021
Bradford L. Frank, MD, MPH, MBA, conducts a Masterclass on how
to provide nursing home consultations for psychiatrists. The
documents Dr. Frank refers to during this Masterclass are available
Frank is a board-certified geriatric psychiatrist who provides
consultations for more than 30 nursing homes in North Dakota. He
has no disclosures.
- Dr. Frank reviews practical information about documentation,
prescribing, and diagnoses for psychiatric clinicians who treat
individuals living in nursing homes.
- The Centers for Medicare & Medicaid Services has many rules
and regulations governing the psychiatric treatment of individuals
in nursing homes, including special mental status testing, a policy
of gradual dose reduction, and restrictions on how long certain
medications can be used.
- Even for geriatric patients who live in nursing homes, a full
past psychiatric history, including substance abuse and social
history, is essential to diagnosis and treatment. To obtain these
histories, Dr. Frank sends documents to the nursing home to be
completed ahead of time, and then, while he starts to make his
differential diagnoses, he talks with the nursing staff about why
they want the consultation.
- The Brief Interview for Mental Status (BIMS) is a 15-item
mental status exam mandated by the CMS during nursing home
evaluations. A score of 13-15 indicates that a patient is
cognitively intact, 8-12 indicates moderately impaired, and <8
is severe impairment. However, even patients with a BIMS score of
15 may still be diagnosed with moderate dementia when a more
sensitive neuropsychiatric assessment is used. Patients should also
complete a Patient
Health Questionaire–9 and have labs done as they would in a
- The assessment must also address gradual dose reduction using
language from the CMS (see below).
Prescribing and medications
- Gradual dose reduction is a CMS policy defined as “the stepwise
tapering of a dose to determine if symptoms, conditions, or risks
can be managed by a lower dose or if the dose or medication can be
discontinued.” In collaboration with nursing home staff,
prescribers must attempt to taper the doses of psychotropic
medications during at least two quarters during the first year of
the prescription and at least annually thereafter.
- The Food and Drug Administration has provided a black-box
warning for the use of atypical antipsychotics in geriatric
patients with dementia, and their use in such patients is audited
by the CMS. To avoid censure and low ratings, nursing home
clinicians must prescribe antipsychotics only for psychotic
symptoms, such as hallucinations and delusions, and not for
“dementia” or “agitation.”
- As-needed (PRN) antipsychotic medications can only be used for
14 days, and to extend the period another 14 days, the patient must
be evaluated in person by the primary prescriber. PRN medications
from other drug classes, such as benzodiazepines, can be used for
longer without an exam, but their timeline must be specifically
- Psychiatrists are most commonly consulted in nursing homes for
agitation, and antipsychotics are not supposed to be used solely
for agitation. Dr. Frank recommends citalopram (maximum dose of 20
mg), then escitalopram, Nuedexta (dextromethorphan HBr and
quinidine sulfate), and pimavanserin for agitation associated with
Alzheimer's disease (AD).
- Research based on autopsy findings has concluded that mixed
etiology dementia is the most common type of dementia. On autopsy,
AD is concurrently found with either vascular dementia, as
evidenced by cerebral infarcts, or Lewy body
dementia. To use cognitive enhancers that are FDA approved only
for AD, Dr. Frank will update the diagnosis to multiple etiologies
with a severity specifier.
- Frank discusses that nursing homes are reimbursed at a higher
rate for the diagnoses of restlessness and agitation (R45.1), noncompliance
and these are helpful diagnoses because they describe behaviors.
Nursing homes use ICD-10 codes to diagnoses dementia with or
without behavioral disturbance. For psychosis not attributed to
delirium or severe dementia, Dr. Frank uses psychotic disorder with
delusions or hallucinations because of a known physiological
condition (F06.2 and
agencies recommend against use of the unspecified diagnoses.
Center for Clinical Standards and Quality/Survey &
Centers for Medicare and Medicaid Services. 2016 Mar 25:
Minimum Data Set – Version 3.0. Resident Assessment and Care
Brief Inventory Mental Status exam: 7-8.
Bennett DA et al. Curr
Alzheimer Res. 2012 Jul 9(6):646-63.
Yunusa I et al.
JAMA Netw Open. 2019;2(3):e190828.
Show notes by Jacqueline Posada, MD, associate producer of the
Psychcast; assistant clinical professor in the department of
psychiatry and behavioral sciences at George Washington University,
Washington; and staff physician at George Washington Medical
Faculty Associates, also in Washington. Dr. Posada has no conflicts