Setting the Bar

Author: Michael Wasserman MD

Originally published: Wednesday, December 16, 2015

Is it idealistic to want older adults to get the best possible medical treatment? If our health care system is not doing a good job in this regard, is it appropriate to set a low bar for improvement? How do we feel when our parents and grandparents are taken for granted in a health care system that seems to value profit over quality? How do we want to be treated as we age?

Twenty-five years ago, when a nurse would call me from the nursing home and ask for an order for antipsychotic medication because a demented resident hit her, my response was, “What did you do to make her hit you?” Today, nearly one in five nursing home residents receives antipsychotic medications, and we laud that as a significant improvement from when it was one in four.

Very few people are comfortable with seeing a nursing home resident tied down by physical restraints. Yet antipsychotic medications are no different, except that they are chemical restraints. Are there residents that need them? Absolutely, but most experts agree that number is under 5%. We clearly have a long way to go before we reach the point where fewer than 1 in 20 nursing home residents is receiving an antipsychotic medication. Why is this the case?

To a hammer, everything is a nail. Physicians today are generally trained to treat problems with medications and procedures. When a nurse identifies aggression or agitation in a resident with dementia, what is the most likely treatment response from a physician? It’s going to be a medication. In 2006, Schneider et al. found that there was not good evidence for the efficacy of such an approach. There is also plenty of evidence available that there are a myriad of approaches to reducing behaviors in people with dementia. The National Nursing Home Quality Care Collaborative found that nursing homes that focused on a number of nonpharmacologic approaches have been able to achieve a significant reduction in the use of antipsychotic medications. It should come as no surprise that these approaches are all consistent with the concept of person-centered care. These are the five approaches:

1. Design and create a calming environment.
2. Create meaningful relationships.
3. Provide meaningful activities.
4. Identify and treat physical and mental conditions.
5. Define a consistent approach to minimizing the use of antipsychotic medications.

If we set a goal of reducing antipsychotic medications rather than a hard goal of what the actual threshold should be, we run the risk of becoming complacent with an improvement that is far from what we would define as the highest quality of care. It is time that we set the bar where it should be. Let’s all work together to minimize the use of antipsychotic medications in nursing home residents. Where do we want to set the bar for our parents and grandparents?