Well, I’m back from Italy and have a lot of rants to share. But webmaster Kavan Peterson suggested I mention last Saturday’s large Boston Globe article on the problem of antipsychotic overuse in nursing homes, so I’ll start there: (http://www.boston.com/news/local/massachusetts/articles/2012/04/29/nursing_home_residents_with_dementia_often_given_antipsychotics_despite_health_warnings/?page=1).
This article details the extent of off-label antipsychotic use in nursing homes, particularly in Massachusetts, where rates are among the highest in the country (28% of all people in Massachusetts nursing homes who do not have an FDA approved indication for these drugs–such as schizophrenia–are receiving them).
The article thoroughly discusses the high level of prescribing, the low level of attempted drug tapering (even after symptoms resolve), the significant side effects of the drugs, and the concerns raised by both consumers and by the regulators about this issue. The article also recorded several responses from nursing homes about the need for the medications–not surprisingly, every home interviewed (including a home with 71% antipsychotic use) claimed that all of their drug use was necessary and appropriate. But a follow-up article http://www.boston.com/lifestyle/health/articles/2012/04/30/finding_alternatives_to_potent_sedatives/?page=3) puts the lie to these claims by showing that a number of homes have provided better care without the drugs.
Anyone who reads this blog and the other pages of ChangingAging is no stranger to our criticisms of such drug overuse. So without rehashing the points of the two articles, or all of the details of previous diatribes, I’d like to just highlight a couple of important facts that need to be considered as the media becomes more and more aware of this problem:
1) This is not simply a nursing home problem. Nursing home drug use is easily audited, and they are therefore ripe for criticism. While that criticism is justifiable, the big secret is that antipsychotic overuse occurs everywhere, and what little research has been done suggests that the absolute magnitude is much greater in the community than in nursing homes.
My own audit of a cohort of 200 people who came to St. John’s Home in 2007 showed that of those with a moderately-severe or severe level of cognitive disability, fully 50% had been taking antipsychotic drugs in their own homes before they moved in! Indeed, many of those likely had hospitalizations and eventual placement at our home due in part to the pills they were taking. If you estimate that for every person with dementia who lives in a nursing home in the US, there are at least 4-5 living in the community, then the numbers can quickly add up. A recent published study of community-dwelling people with dementia found similarly that antipsychotics are widely used in all living environments.
2) It’s time to stop simply focusing on the antipsychotic drug as the “bad guy”. There is a much larger issue at fault here, and that is the basic notion that behavioral distress is a symptom of a diseased brain and therefore needs some sort of pill. Antipsychotics get all the attention because of their well-publicized side effects, but the real problem lies in using any pill for a situation where there is an unmet need or an inability to cope with the environment one is forced into.
The homes profiled in the second article have largely realized this. Rather than looking at distress as a “problem behavior”, they have pursued a path that emphasizes relationship, an understanding of each person’s history and individuality, and an ability to follow individual rhythms and adjust the environment, in order to help each person succeed in finding comfort and meaningful engagement. If several nursing homes can completely eliminate their use of such medications, as about 150 in the country have, then it is hard to argue that any nursing home needs to use these drugs, except in the rarest circumstances.
3) The key to solving this problem in long-term care lies in transforming our model of care. This is what many would call “culture change”, though I am pretty much done with that term, as it has become too vague and improperly applied, which has rendered the term virtually meaningless.
The idea that antipsychotics are bad is one that CMS and state watchdogs have latched onto, but it is of no avail if nursing homes are not given an alternate path to follow.
A transformational approach to care has three components. First is a new view of dementia; one that cultivates strengths, rather than stigmatizing and disempowering the individual. This approach requires that we see a person with dementia as a whole person who, due to disability, is experiencing the world differently than she used to, and therefore needs to be enabled to continue to engage successfully. This also involves honing our ability to be fully present, and to find better ways to connect with people who may not process information the way we do.
Second is the physical transformation of the environment. This not only applies to creating buildings and physical layouts that reflect the values of home and familiarity, but also that create comfort, independence and functional competence.
Lastly, and perhaps most important in my mind, is an operational transformation. This means that the myriad ways in which long-term care operates must be consistent with the new philosophy we espouse. This applies to how decisions are made, who makes each decision, how information is communicated, and how conflict is resolved. In addition, it applies to which staff actions are encouraged by organizational policies and how performance is measured. A home that grades staff members on the number of tasks they complete in a shift will never create an atmosphere of flexible, individualized care.
This last point cannot be over-emphasized. It is the reason why so many organizations get stuck in their transformational journey. Also inherent in such operational change is a move away from the rigid schedules and routines that are dictated by institutional approaches to medical and nursing care, toward a more natural flow of daily life (see my recent post on “sundowning” for a prime example).
4) The most successful organizations have a medical director and a director of nursing who are strong believers and champions of medication reduction and innovative approaches to care. Unless these two individuals are driving the process, it will never succeed.
I’ll be speaking more about these topics at a government-sponsored symposium in DC in June. And much more educational information will be result from a meeting of experts that was held last month at CMS. Stay tuned.