How do we reach new antipsychotic goals?
G. Allen Power
In June, McKnight's reported that CMS is pushing for further reductions in antipsychotic use for people living with dementia in nursing homes. The 19.4% nationwide reduction achieved by the end of last year is just short of the 20% target set by CMS in 2012. There is a push for a total reduction of 25% this year and 30% by the end of 2016.
These are laudable goals, but can they be achieved? There is reason for concern. While there is great variation among individual homes, a graphing of the quarterly numbers over the past three years shows a pronounced flattening of the curve over the past year. Both the national numbers and those of most individual states show that they are reaching a plateau.
In fact, nearly half of all states found their antipsychotic use to be level or slightly increased over the last two quarters of 2014, and only 8 states had an absolute reduction of 2% or more over the prior year. Clearly, nursing homes have found all of the “low-hanging fruit”—the people whose drugs could be easily stopped—but most are having trouble figuring out how to take it to the next level.
Having been involved in the CMS partnership to reduce antipsychotic use, and in education of nursing homes on this topic, I think there are two important barriers to success that need to be overcome: educational and operational.
From an educational standpoint, there are simply too many seminars being offered that rely on outmoded concepts. Many of the available courses continue to promulgate a deficit-based view of dementia that is highly stigmatizing. Major curricula are being promoted that still state that the person is “disappearing,” “demented,” or has “problem behaviors” that must be “managed.” You would think that Tom Kitwood's book, Dementia Reconsidered, had come out last week, instead of 18 years ago.
Such an approach positions the person's brain changes as being primarily responsible for their distress, without adequately understanding the person's experience within a relational, environmental, or historical context. The focus is on reactive “interventions” that may defuse an acute situation, but do nothing to create sustained success in promoting well-being. And a philosophy that blames the distress on brain changes is a slippery slope to continued use of psychotropic drugs.
This is not just a nursing home problem; this is a basic paradigm problem that permeates society, and one that unfortunately is perpetuated by many in the medical profession, media, and advocacy organizations. Evidence of this is demonstrated by recent data that suggests that the total number of people living with dementia who are taking antipsychotics is likely much higher in the community than in nursing homes, a fact which gets little or no attention from media reports or educational initiatives.
Albert Einstein said, “We cannot solve our problems with the same thinking we used when we created them.” Sustained success in antipsychotic reduction requires that we shift to innovative educational approaches that are proactive and strengths-based — that focus on creating well-being, not simply calming distress.
The second barrier that nursing homes face is their inability to heed the advice of CMS' Michelle Laughman, and “embrace culture change.” There is plenty of lip service being given to “person-centered care,” but talk is cheap. Many homes have adopted the language or transformed their physical layouts, but few have done the important work necessary to operationalize the philosophy. This is where the rubber meets the road.
A perfect example is the number of places that advertise their devotion to individualized care and relationships, and yet continue to rotate their staff assignments on a regular basis. Despite a mountain of evidence showing advantages in quality of care, quality of life, survey results, staff turnover, and even lessened resistance to care in homes using dedicated staff assignments (not to mention the familiarity, trust, and overall sense of security this enhances for people with memory difficulties), many, if not most nursing homes and assisted living communities have made no effort to take this important step.
The way to significantly reduce antipsychotic drugs in a sustainable manner is to embrace an approach that sees the whole person and shifts our operations to fit their needs, rather than demand that people with changing brains conform to ours. This is neither fast nor easy, but it is the only way to get off the drug “plateau.” Organizations who have seriously undertaken this journey, such as the Windsor Healthcare homes of New Jersey (2% to 6% antipsychotic use) or Beatitudes Campus in Phoenix (0% - 2%), have set a standard to which everyone should aspire.
G. Allen Power, M.D., FAACP, is the author of “Dementia Beyond Disease: Enhancing Well-Being,” published in June by Health Professions Press. A geriatrician, he has served on the technical advisory panel for the Centers for Medicare & Medicaid Services for their national antipsychotic drug reduction initiative. He is a clinical associate professor of medicine at the University of Rochester.