Editor's Note: Dr. Scott Irwin of the Department of Psychiatry at The Institute for Palliative Medicine at San Diego Hospice discusses a new plan by the Centers for Medicare & Medicaid Services (CMS) to reduce the use of antipsychotic medications in nursing home residents.
On May 30, 2012, CMS announced they will probably worsen care of nursing home patients with dementia. Although their purposes was to announce a partnership to improve dementia care in nursing homes, which is a laudable and much-needed goal, the sole focus of this initiative seems to be decreasing the use of antipsychotic medications. Their intention, of course, is to decrease the misuse of antipsychotic medications.
Unfortunately, with an announced goal of reducing all antipsychotic use by 15% by the end of 2012, that means that patients who are helped by the medications will end up being harmed.
It is already very difficult to get nursing homes to use antipsychotics appropriately. In my experience, some nursing homes will not admit patients who are taking antipsychotics, even if these agents are being used appropriately, even if medical decision-making and failed trials of other medications are well documented, and even if prescribed by a psychiatrist. Some nursing homes will pick and choose which antipsychotics are appropriate and which are not, totally ignoring the evidence base that they are all pretty similar with regard to effect and side effects.
Why do they do this? Fear. They are afraid of regulatory surveys and would rather avoid proper care of patients to appease the regulators than stand up and do what is right. Why? Because the surveyors are immovable, and taking inadequate care of a few patients is better than being shut down and not being able to care for many patients.
What else are they to do? This new initiative will only serve to heighten these issues.
The outcomes that will drive this initiative are reducing use of antipsychotics and highlighting to the public each nursing home's use of these agents. So what will the nursing homes do? They will decrease use and avoid admitting these patients at all costs. CMS will get what they want -- decreased antipsychotic use -- but they probably will not get improvement in care and relief of suffering in patients and families. Why wouldn't they make such improvement, along with better training and appropriate use, the outcome that drives appropriate antipsychotic use?
CMS does state that they are beefing up efforts at nonpharmacologic management, which is needed and should always be a part of dementia care. But these efforts fall short for patients who need pharmacologic management. The current evidence for the efficacy of these medications in dementia is mixed, as is the evidence for some alternative medications. The majority of physicians still use antipsychotics first-line or turn to them to manage symptoms of dementia when other methods fail.
So, while we should dramatically improve our dementia care, increase use of non-pharmacologic interventions, explore alternative medication approaches, and increase appropriate use of antipsychotics, we will unfortunately not get there with the approach CMS has chosen. If increased quality of life and decreased suffering, for both our patients and their families, is the goal, then that should be the outcome that drives nursing home behavior -- not misguided fear.
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Poster Comment:
What else are these perfunctory pillpushers to do? Also illustrates the redundancy of bureaucrats. And if you're a nursing home patient/candidates resolve to be on your best behavior to avoid synthetic sedation.