The unspoken cost of restraint
Charles de Vilmorin
Thankfully, the practice of using physical restraints for older adults living with dementia has largely been relegated to the past. In fact, Linked Senior client Kendal Senior Living Communities led the way nationally in prioritizing the elimination of restraints with their participation in the Pennsylvania Restraint Reduction Initiative. Between 1996 and 2015, Pennsylvania itself has experienced a 97.6% drop in physical restraint use (see chart below).
Unfortunately, the senior care industry has increasingly moved from using physical restraints to chemical methods of restraining older adults in their care. According to a recent AARP article, more than 1 in 6 nursing home residents living with dementia are being administered antipsychotic drugs they do not need. These pharmacologic interventions are too often used to address the “behaviors” associated with Alzheimer's disease and other dementias. They are expensive, ineffective and most importantly dangerous. The Food and Drug Administration has continuously alerted healthcare providers that the use of antipsychotic medications to treat older adults living with dementia increases the risk of mortality.
Recently, The National Partnership to Improve Dementia Care in Nursing Homes, released their Antipsychotic Medication Use Data Report. An encouraging statistic from their findings was that 2011 (Quarter 4) to 2017 (Quarter 1) the number of long-stay nursing home residents using antipsychotic drugs dropped 34% to a national prevalence of 15.7%. Although it is encouraging to see prevalence of antipsychotic use drop by more than one third, it remains troubling that there is still work to be done to eliminate the prescribing of these drugs to those living with dementia.
The True Cost
What is this reliance on antipsychotics costing us?
Recent discussions in senior care have been focusing on the use and overuse of antipsychotic drugs for people living with dementia. It is important to understand the actual cost of these drugs. Assisted living communities are often burdened with the staggering cost of antipsychotic drugs as part of their cost of care, meaning they cannot invest the amount that they would like in engagement activities and education. Skilled nursing facilities, are not usually paying directly for the cost of antipsychotics (rather Medicare, Medicaid and Private Insurance are the payers). But they do face rehospitalization, compliance, risks in addition to jeopardizing the health and wellbeing of their residents by using drug-based interventions rather than person-centered, individualized therapeutic engagement.
A study published in 2009 entitled “Use of Antipsychotics among Elderly Nursing Home Residents,” used the 2004 National Nursing Home Survey (NNHS) to show that 32.88% of nursing home residents living with dementia in nursing homes were taking antipsychotic medications. The Office of the Inspector General outlined in a report from 2011 that of the 2.1 million nursing home residents, 304,983 had at least one Medicare claim for an atypical antipsychotic drug from January 1 through June 30, 2007. Of the 8.5 million claims during this time for atypical antipsychotic drugs for all Medicare beneficiaries, 20% were claims from nursing home residents amounting to $309 million.
Providers can avoid the costs of chemical restraints by committing to decrease the percentage of residents living with dementia using antipsychotic drugs. If a skilled nursing facility currently has 20% of residents living with dementia using antipsychotic drugs, a reduction of just 4% would mean, assuming the SNF has 110 beds, a total of 4 residents would no longer be taking the drugs which cost about $2,000 per year per resident, totaling $8,000 per facility per year.
Simply put, there are ethical, emotional and financial costs that go hand in hand with the decision to use antipsychotics as a form of restraint. The decision by any healthcare provider to incur such costs is troubling, especially when non-pharmacological strategies are safe, cost-effective and address the individualized needs and interests of each resident regardless of their current stage of Alzheimer's disease and other dementias.
Aside from being the right thing to do, it is important to use meaningful, non-pharmacologic strategies because reimbursements for care now depend on the effective use of these interventions thanks to the new Medicare and Medicaid Requirements of Participation, the second phase of which becomes effective November 28, 2017.
It is time to pay attention to the growing number of studies that are exploring the effectiveness of art, music, dancing, exercise and nutrition on the health and wellbeing of older adults living with dementia. However, a nursing home community cannot simply use a non-drug intervention and anticipate immediate results and a person-directed status.
Charles de Vilmorin is the CEO of Linked Senior.