Don’t Hold Person-Centered Care To Higher Bar

by, Dr. Al Power, ChangingAging Contributor

Recently, I have been thinking a lot about the “lack of empirical evidence” label that hounds culture change enthusiasts. Here are two examples:

1. I just read an article from The Gerontologist, (2008), in which Rahman and Schnelle reviewed the history of the long-term care culture change movement in the U.S. over the previous decade. They noted an increased interest, momentum and visibility in the prior three years, but pointed out (correctly) the lack of well-published empirical data to date.
2. After writing the New England Journal of Medicine to criticize the recent antipsychotic withdrawal study (see my January 15, 2013 post), the authors responded by saying that person-directed approaches were certainly promising, but had yet to be well tested in empirical trials.

I was trained in science and am a big believer in empirical methods, wherever they can be applied. I would also love to see more published evidence of the efficacy of the transformational models of care being developed within the culture change movement. These are often difficult to study, due to the slow, multifaceted nature of transformation, but at the very least, we need more well-planned studies that compare a variety of outcomes between culture change adopters and traditional models.

All of that is well and good. Here’s my problem: Innovation is too often held to a standard that traditional approaches never had to meet.

Let’s go back to the two examples above:

1. There have never been empirical studies to evaluate whether our current system of long-term care produces quality outcomes. Maybe that’s because it’s the only system we’ve known for half a century. But consider what we know about: staff turnover rates, antipsychotic and physical restraint usage, reports of abuse, failures to meet regulatory standards, and the public perception of life in a nursing home. We actually have a wealth of data proving that our current long-term care system is an abject failure.  And yet we hold up change efforts, because we need better evidence.
2. Next, let’s talk about person-directed approaches to dementia. Once again, they are hard to study empirically for a variety of reasons, not the least of which is the hold of Big Pharma on funding of research in this area. But once again, let’s scrutinize the current widespread use off-label use of antipsychotics — the best studies show no more than 18% improvement behavior, with 50-60% higher mortality… and yet over a million Americans with dementia take these drugs and it is still accepted as good practice. Drugs like Ritalin and Neudexta have been liberally sprinkled into the dementia cocktail with little empirical study to back them up. The FDA has approved a larger (read: newly patented and expensive) form of Aricept, even though the studies showed no added benefit and increased side effects.

So my problem is that new ideas shouldn’t have to jump over so many hurdles to funding and implementation if the old ideas have such a terrible track record. Let’s apply the same scientific standards to both, rather than throwing up smokescreens to preserve a failed status quo.