Antipsychotic Drug Reduction in Nursing Homes

OCTOBER 15, 2013
“Nursing Homes Drug Use Falls” was a headline in a recent Wall Street Journal. The story is about how the Centers for Medicare & Medicaid Services has worked with the nursing home industry to reduce the use of antipsychotic drugs in elderly nursing home patients. The goal was to reduce the use by 15% by the end of 2012, but the reduction achieved was only 9%. This article described the efforts that were undertaken to achieve this goal.

The story reported that some want more stringent efforts to be taken to achieve the goal, while others felt that the target might be reached a year later than planned. As I read the story, I was reminded of my own work back in the early 1960s which involved looking at the opportunity for pharmacists to become involved in nursing homes. Much has changed in the industry since I published my first paper on the subject. Yet in many ways it hasn’t. There is still a need for someone to help the patient and/or the caregiver make the best use of their medications—the pharmacist’s role.

But a personal story reminded me that this is not always easy to do in a manner that when looked at in hindsight a researcher would determine you have done the right thing. A good friend has been institutionalized in an assisted living facility with the diagnosis of dementia. In hindsight, he probably should not have been placed in this facility but the family was looking at convenience to visit as well as cost in making the decision. In order to try to keep him there, medication to calm him down was sought and prescribed. All decisions were made with the desire to do what was best, but in hindsight someone might say here is more evidence that we are using too many antipsychotic drugs in the institutionalized elderly.

That may be true, but the reason may not be that no one cares but that the prescriber is trying to help by the action taken. Of course, it turned out that the action taken didn’t work in this case and the patient ended up being transferred. Since the intervention didn’t work, then you can say in hindsight that it shouldn’t have been tried? Would that wife or daughter have accepted the idea of not trying, and would that prescribing physician have felt good if he hadn’t tried? Probably not. Those who think there is an easy solution for preventing the misuse of antipsychotic drugs in nursing homes probably haven’t been working closely with patients and families dealing with dementia.

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