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Nursing Professor Is A Change Maker For Elder Care  

Judy LucasAssociate Professor Judith A. Lucas, Ed.D., APRN, GCNS-BC, has devoted much of her professional work to issues related to safety and quality of care for geriatric populations living in community home care, assisted living and nursing homes (NH). Her focal research on the inappropriate use of antipsychotic medications (APM) in dementia care has influenced policy and education changes through the Centers for Medicare and Medicaid Services (CMS), along with many other state agencies, organizations and practitioners. Her studies now examine the effects of recent federal policy changes as a result of previous research done by her and other colleagues in the medical, health economics and pharmacoepidemiological disciplines.  

Lucas's education as a geriatric nurse specialist in community health and long-term care brought her to Rutgers University College of Nursing where she served as Assistant Professor and Teaching Nursing Home clinical faculty. There, she began implementing dementia care standards and including BSN and graduate students in geriatric education and research projects. Her position as Assistant Research Professor for Rutgers University Institute for Health, Health Care Policy and Aging Research's Division on Aging, Center for Education and Research on Mental Health Therapeutics (CERT) and the Center for State Health Policy, where she led the Long-Term Care Initiatives, further developed her investigation of resident, organizational, and regulatory policy factors affecting long-term care (LTC).

According to Lucas, limited resources for staffing and training are core challenges for LTC and support services for person-centered care that have affected approaches to long-term care for persons with dementia. Persons with dementia frequently experience distressing behaviors and psychological symptoms (BPSD) such as agitation, crying out, and resisting care. "The culture had been to medicate with antipsychotics (APMs) first," she states. APMs have sedating properties, and when provided to NH residents with BPSD, were viewed as a form of "chemical restraint". Significant problems arose with the introduction of new antipsychotics, which were believed to have safer side effect profiles than first generation APMs. Once the U.S. Food and Drug Administration (FDA) granted approval of these drugs in the late 1990's, their use rapidly increased in nursing homes for BPSD. However, by the mid 2000's, it became evident, and some Rutgers studies showed, that APMs could result in increased risk of mortality and other significant negative outcomes in persons with dementia such as falls, hip fractures, pneumonia and strokes. Subsequently the FDA imposed black box warnings (2005, 2008) cautioning against APM use in persons with dementia. Although the FDA advisories brought about public awareness, prescribing of APMs persisted at high levels in NHs to manage BPSD, despite further evidence of minimal clinical benefits and serious adverse effects.

Lucas's growing concerns about quality and processes of LTC led to her early research comparing measures of inappropriate antipsychotic (APM) use that ultimately contributed to influencing policy changes for nursing homes. She states, "We had known that they [APMs] were not as effective for years, but they continued to be used routinely. I wanted to find a way to help change these accepted and all-too-common practices." Her work on CMS guidelines studied inappropriate use of antipsychotics in nursing homes nationally and examined prescribing patterns, effects of state regulations, staffing policies and FDA warnings. CMS then began its National Partnership to Improve Dementia Care encouraging research, education and sharing effective programs online, which led to early policy changes. Her findings were included in several publications on risks and outcomes with colleagues at Rutgers, Harvard, Columbia Universities, University of Maryland, Baltimore, and Miami University, Ohio.

Dementia presents many challenges for caregivers in LTC. One might say that it is about funding priorities for elder care. Nursing homes and community based LTC services are not set up for specialty psychological services. If facilities/services are underpaid by Medicaid, staffing and training on alternatives to drug use will continue to pose challenges and poor outcomes. Lucas began to do more research and education on what works to improve care in an attempt to develop a more person-centered environment. Personalized activities, relief of pain and anxiety, comfort measures such as massages/music, and meeting each person's physical needs were promoted to induce a culture where psychotropic medication would be last and not first. Her work also encouraged training programs for families, caregivers, and students for quality of life and care for persons with dementia.

One opportunity came between 2012 and 2014 when she participated with a panel of Geriatric Nursing experts which developed the CMS Nursing Toolkit that promoted behavioral health improvement by disseminating research and education on effective non-pharmacological interventions. Clinicians, faculty and students can use these resources for developing programs and research.

Lucas's current work now examines the effects of the CMS Partnership policy changes, utilizing national data on effects of regulations for long-term care such as public report cards, deficiency citations and staffing standards on prescribing practices. Since the policies were initiated in 2012, APM national use proceeded to dramatically decrease by 20-22% However, some studies, including one by Lucas, have suggested potential substitution of anti-anxiety/hypnotic medications, and these are now being monitored by CMS.

As the U.S. older adult population continues to grow, with many living longer, improving the quality and safety of LTC and support services has become an increasingly vital national issue. Through quality initiatives, research meetings, panels, papers, public reporting and grants, the work of Judith Lucas and her colleagues has been a catalyst for change. "This [work] is extremely meaningful for me and the well-being of the public-at-large. I saw needs for care improvement and decided what my professional goal would be." Quotes Lucas, "We need to change our drug-first culture and focus on each person's needs and capabilities in LTC. Nurses have a great opportunity to champion this change."

Judith A. Lucas is Associate Professor and Assistant Chair in the Seton Hall University College of Nursing, Department of Undergraduate Nursing. She has taught in the RN to BSN and CNL (Clinical Nurse Leader) graduate programs, and currently teaches Research, Community Health Nursing and Gerontological Nursing students. She continues to involve students at all levels in research related to geriatric and long-term care.

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