Use caution in antipsychotics reduction
G. Allen Power
McKnight's reports today that CMS has recently increased its goal for antipsychotic reduction in nursing homes to 25% by the end of 2015 and 30% the following year, based on 2011 levels. Their initial goal for nursing homes of a 15% reduction in use was reached this year, with an average reduction of nearly 18%, to an overall national level of 19.8% (compared to nearly 28% in a 2001).
As the author of the 2010 book Dementia Beyond Drugs, one might expect me to raise an unqualified cheer for these efforts. However, I would like to offer a slightly more tempered, “Yes, but…”.
It is true that I began speaking out about the misuse of these drugs long before they came to national attention. And it is also true that I have often referred to them as “the physical restraints of the 21st century” (meaning that they are also largely ineffective and quite dangerous for people living with dementia, and that I believe our learning curve will eventually render them equally obsolete).
But as I applaud the efforts of our providers and regulators around this important initiative, I would like to make two cautionary points.
The first is that antipsychotic prescribing did not simply occur because of uncaring physicians who forced them on unwilling elders, staff, and family members. Many of the people taking these medications have been truly distressed, and the doctors were enlisted to try to help in any way they could, which amounts to asking for medications. We have all bought into this paradigm because of our lack of knowledge of other ways in which we could support people and meet their needs.
Therefore, setting numerical targets for drug reduction is a bit of a “cart before the horse” scenario, if we do not first learn how to care differently. Simply stopping a given number of sedating medications will no doubt lead to increased distress, unless we possess knowledge that we did not have when the drugs were started in the first place.
This is why education must always come first; and it must be innovative education on new ways of understanding people who live with cognitive change. Such education is out there, starting with the Hand In Hand toolkit distributed by CMS last year. There are many other excellent seminars available. I am currently in Mississippi leading a series of courses supported by a CMS grant that is funding the class for all state surveyors and three representative staff (including certified nursing assistants) from all nursing homes in the state.
This ties into my second point of caution, echoed by the comments of LeadingAge's Larry Minnix in Elizabeth Newman's article. This is not a nursing home problem; it reflects a societal paradigm about what dementia is and how we should view and support people who live with the condition.
There is not much published evidence outside of well-documented skilled care settings, but the few data we have suggest that, while there are over a quarter million Americans still taking antipsychotics in nursing homes, there are likely a million or more doing so in the community! My anecdotal experiences suggest that these people are not being addressed with the same degree of urgency, nor with similar educational efforts.
The answer to both concerns is to change the way we view people with changing cognitive abilities, shifting our focus from treating disease and “fixing behavior,” to cultivating strengths and restoring well-being. We must become much more than dementia-friendly in our society (a paternalistic term I have never liked). Instead we need to become dementia-inclusive in our communities and dementia-capable in our approaches to support and care. That is the only way to truly achieve sustained reduction of psychotropic medications, and a true quality of life for those we serve.
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.