When looking broadly at the numbers of nursing home residents who were physically or chemically restrained for the past twenty years, the dramatic reduction in physical restraints and simultaneous increase in psychotropic drug use seems to suggest that providers simply substituted drugs for bed rails and lap belts. A close look at the data and factors driving restraint and drug use creates a more complicated picture.
Psychotropic drug use in nursing homes fell dramatically in the late 1980’s and early 1990’s in the aftermath of the Federal Nursing Home Reform Act (1987) and the implementing regulations. In the mid-1990’s, with the rise of second generation (atypical) antipsychotics and SSRI antidepressants and all of the marketing accorded them, drug use began to rise again, spiking in the early 2000’s. While psychotropic drug use ebbed and flowed, physical restraint use declined just about every year from 21.1% in 1991 to somewhere around 3% today.
A new study in the Journal of the American Geriatrics Society (Vol. 62, pp. 454-461 (2014) claims that public reporting of nursing home physical restraint use rates, which contributed to declining use, did lead to an increased use of chemical restraints in nursing homes. The authors of the study compared antipsychotic drug usage trends in nursing homes with publicly reported physical restraint rates to nursing homes that were exempt from public reporting and found that antipsychotic use increased at a higher rate in the reporting nursing homes. In other words, when a nursing home was given incentives to reduce physical restraints, they increased chemical restraints as a substitute. The authors concluded that “aspects of quality that are targeted in quality improvement efforts and incentives will receive attention, whereas other, non-targeted areas may be neglected and even worsen.”
The idea that increasing attention on one care measure leads to tradeoffs in other areas is not new and something that should be considered whenever efforts are made to improve one aspect of care. With regard to CANHR’s and the federal government’s campaign to end the misuse of antipsychotic drugs, great effort has been made to concentrate on improving dementia care in general as opposed to questioning antipsychotic use alone. And as a result, national statistics show that use in all four classes of psychotropic drugs is down – not just on antipsychotics. Approaching one problem in care holistically and in context to other care concerns not only alleviates the targeted problem but bears broader benefits to care as a whole.