Reducing the overuse of antipsychotic medication: A person-centered care approach
Vice President and Corporate Medical Officer of Presbyterian Senior Living
In recent weeks, a study by the Human Rights Watch has shed light on a serious problem across many facilities where seniors live in America: the over-prescription of antipsychotics to unnecessarily medicate individuals with dementia.
Despite all of the recent discussions around how many facilities address this issue, few have been able to point to a solution. At least, not one that holds both medical professionals in senior care facilities and doctors in hospitals accountable for their roles in appropriately prescribing these drugs. We know that it is every medical professional's job to help reduce the inappropriate use of antipsychotic medications. But the big question is, how?
As vice president and corporate medical director with Presbyterian Senior Living (PSL), a leading provider of senior housing and care, I've found that the first step is to identify the origin of where and when the medication was first prescribed. Many times, antipsychotic treatment can begin with a doctor prescribing it during a hospital stay. If nursing homes want to reduce their antipsychotic use, they need to routinely re-evaluate the medication that an individual was given when they return to a long-term care setting.
The second step involves communication between medical professionals in senior living care and the hospital. While most medical professionals believe that the regular use of antipsychotic medication to control the behavior of residents with dementia is not the appropriate solution, few alternative solutions have been pointed out to fix this serious issue. This is largely due to a lack of collaboration.
Therefore, to really make progress on this issue, there needs to be continued discussion where medical directors in post- acute care and doctors in hospital settings come together to identify alternative solutions for individuals with dementia.
We have made reduction of such medications a priority across our health centers within the PSL network. Specifically, we've achieved significantly low rates of antipsychotic prescriptions by not only acknowledging the problem, but also by offering solutions through healthy alternatives to medication.
These solutions greatly improve health outcomes and quality of life for seniors. With these alternative solutions, PSL has been able to reduce its use of antipsychotics well below national and state averages by replacing medication with natural, person-centered treatments.
So how do we do it? Our staff starts by routinely re-evaluating every medication that a resident receives when he or she returns to us following a hospital stay, and critically, eliminates any unnecessary medication when possible. Newly prescribed antipsychotics are often the first to be eliminated.
To wean individuals off of the unnecessary medication, we have found that natural, behavioral approaches on a community-wide basis are most effective. But while some of these efforts are implemented at the community level, PSL's approach is not “one size fits all.” Rather, the solutions stem mostly from our mission to provide tailored, “person-centered care.” Each individual is evaluated on a case-by-case basis to find the right approach for residents with dementia, who can become easily agitated.
Some behavioral approaches lie in controlling the environment individuals are in to maximize their comfort level. Examples of this include noise reduction, using passive light, reducing psychological stimuli, aromatherapy, hand or shoulder massage, or simply changing their seating position. Along with the behavioral approaches taken, potential pains or injuries should be checked for those individuals that have challenges communicating in order to rule out any problems that may have gone unnoticed. Virtual window technologies, which display calming nature scenes accompanied by soothing sounds, also provide a healthier alternative for situations that regularly cause individuals agitation, such as entering the bathing areas.
But, the main thing to remember is that an approach that works on one individual might have the opposite reaction for another individual, so treating residents with an individualized approach is key. For example, compassionate touch, a style of intentional touch through massage, may calm a resident and reduce agitation, but could have an adverse effect on another resident who feels uncomfortable when touched.
Different therapies work for different people. Lumping individuals with dementia into one category and prescribing them antipsychotic medications, or providing a one-size-fits-all approach is not the solution here.
The potential to help these individuals spans beyond just what PSL is doing in our communities today. If more senior living facilities are able to collaborate with doctors in hospitals and develop informed person-centered alternatives, we can begin to address this problem industry wide and make a real impact.
Further collaborating with families, regulators, healthcare providers and the individuals themselves, moves us toward a future where the misuse of antipsychotics in long-term care will be a thing of the past.
Steven Fuller, M.S., Ph.D., DO, is the vice president and corporate medical director at Presbyterian Senior Living and has more than 25 years of experience in healthcare leadership and patient care. Since joining PSL, he has spearheaded implementing new clinical standards, developing systems of accountability that emphasize data collection and empirical measurement outcomes, and partnering with healthcare providers to maintain quality of care for residents.