CANHR’s Comments on Proposed Hospital Antipsychotic Quality Measure

California Advocates for Nursing Home Reform (CANHR) applauds the proposal to create a quality measure based on antipsychotic use in older adults in hospitals. For several years, CANHR has been part of the national CMS campaign to eliminate inappropriate antipsychotic use and improve dementia care in nursing homes. ( Much of this work has led to one inescapable conclusion: many, if not most, inappropriate antipsychotic prescriptions in nursing homes are actually a continuation of inappropriate prescriptions that were initiated in the acute care / hospital setting.

The over-medicalization of behavioral expressions of distress and pain for people with dementia, coupled with the over-reliance on antipsychotic drugs to sedate and subdue people with dementia in hospitals has frustrated many of us working to improve dementia care in nursing homes. There is a belief that all of the best efforts to reduce inappropriate antipsychotic use in nursing homes are somewhat negated if hospitals continue to indiscriminately drug any person with dementia who is briefly hospitalized, precipitating more complicated dose reduction schedules and behavioral care planning.

Hospitals have been slow to consider comfort-focused care strategies for patients with dementia and, rather than observing problematic behaviors as communication of unmet needs, deem them “symptoms” of dementia to be eradicated with powerfully sedating antipsychotics. Behaviors are important messages of need. They are informative, medically useful, and should trigger comprehensive root cause analysis and care planning, not chemical restraint.

As glad as we are that antipsychotic use for older patients may become a hospital quality measure, the current proposal raises concerns over whether the measure will effectively reflect “quality.” In that regard, a broad measure of antipsychotic use that is initiated in the hospital for patients 65 years and older would be best. Excluding patients who are a “threat to themselves or others” will encourage hospitals to simply include “threat to themselves or other” in patient descriptions accompanying a new antipsychotic prescription. “Threat to self or others” could mean many different things to many different people. For example, a dementia patient’s assertive refusal of personal care might be called threatening to caregivers but it could also more accurately be called self-protection to a person who does not recognize caregivers or assume their care is going to be loving or helpful. The “threatening behavior” exclusion would likely be given enormously broad application in practice to insulate hospital antipsychotic use from being reported in the quality measure.

In our vast experience with trying to end inappropriate antipsychotic use in nursing homes, we have found that the best measure of a facility’s quality is its overall antipsychotic use rate, with no exclusions. This measure eliminates much of the gaming that goes into quality measures, forces providers to fully confront its systems of care, and provides the public with the most complete and accurate understanding of a facility’s philosophy of caring for older adults.

In conclusion, we are wholly supportive of the effort to include antipsychotic use in older adults as a hospital quality measure but the current exclusion for patients who are a “threat to themselves or others” will significantly diminish the measure’s ability to reflect true quality.


About achicotel

Anthony Chicotel is a staff attorney for CANHR. His areas of expertise include the rights of long-term care residents, nursing home litigation, health care decision-making, and conservatorships.
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Responses to CANHR blog postings do not reflect the opinions of CANHR or its staff members.

One Response to CANHR’s Comments on Proposed Hospital Antipsychotic Quality Measure

  1. Lydia Gugich says:

    Yet another wonderful article! Thank you for continuing to expose the upside down manner in which people with dementia are cared for. Drugging away normal reactive behaviors is what our loved one experienced. We were relying on the expertise of the facility owners and their workers as we knew little about dementia. In our case, the board and care had their own doctor in an adjacent county and their own pharmacy in another county that delivered drugs to their door. The massive doses did indeed follow our loved one and the list got longer with each hospital visit.

    Fortunately, after learning much about these dangerous drugs from CANHR, our loved one is in a different facility and is off all the unnecessary and debilitating medications. Even though she has dementia, her fun and engaging personality has reemerged and she is a delight to her caretakers…. and, of course, our family has our loved one ‘back.’ Thank you CANHR!!

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