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. (www.canhr.org/stop-drugging) 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.