Adopting Person-Centered Care in Nursing Homes
Too often, nursing home residents with dementia are inappropriately medicated with antipsychotic drugs, several recent reports have shown.
One large study of Medicare beneficiaries showed that more than one-quarter of nursing home residents nationally received antipsychotics between 2000 and 2001, and more than half of the residents taking antipsychotics were given doses that exceeded recommended maximum levels, were receiving duplicative therapy, or had inappropriate indications for antipsychotic use (Arch. Intern. Med. 2005; 165:1280-5).
The increase in antipsychotic use in this population is likely linked to the availability of second-generation, or atypical antipsychotics, which may be prescribed for a wider range of indications than are the first-generation medications, according to principal investigator Becky A. Briesacher, Ph.D., of the University of Massachusetts, Worcester. However, the increase--together with the finding that the drugs are not being prescribed in accordance with guidelines--raises concerns about the quality of care for nursing home patients.
"Most atypicals have been shown to be effective in treating schizophrenia, but in nursing homes, they are increasingly prescribed for other, less appropriate conditions, like memory problems, nonaggressive behaviors, or depression without psychotic features," Dr. Briesacher said in an interview.
The study of Medicare beneficiaries also found that patients treated within the prescribing guidelines were no more likely to achieve stability or improvement in behavioral symptoms than were those treated outside of the guidelines.
Similar doubts were echoed recently by members of the study group for the National Institute of Mental Health's Clinical Antipsychotic Trials of Intervention Effectiveness--Alzheimer's Disease (CATIE-AD). In a report of their findings from a double-blind, placebo-controlled trial of olanzapine (Zyprexa), quetiapine (Seroquel), and risperidone (Risperdal) in more than 400 Alzheimer's disease patients, the investigators determined that treatment with atypicals showed no clear benefit for symptoms of psychosis, aggression, and agitation. In fact, drug-related adverse events offset any advantages, the authors wrote (N. Engl. J. Med. 2006; 355:1525-38).
Conversely, nonpharmacologic approaches for managing some of the challenging behaviors associated with dementia are showing promise. The most effective of these approaches is a concept dubbed "person-centered care."
Person-centered care involves evaluating the psychosocial needs of each patient and implementing the psychological or environmental management options most likely to meet those needs. With respect to dementia, however, person-centered care is a departure from the less individualized model of care that has become ingrained in many nursing homes. Under this model, residents are seen as a set of symptoms rather than as individuals with distinct wants and needs. When residents don't do what they're "supposed to do," the difficult behavior is frequently managed by medication or physical restraint.
In the person-centered care scenario, the source of the agitation would be considered, and the environment might be modified to minimize it. For example, perhaps this individual has always functioned better with a more leisurely morning routine. Allowing the individual to get dressed for the day at her own pace could minimize or avoid this particular source of agitation.
Implementing a system of person-centered care requires a huge culture shift, but doing so has multiple rewards, Dr. Louis Mudannayake, medical director of the Cobble Hill Health Center, a 520-bed nonprofit nursing home in Brooklyn, N.Y., said in an interview. As part of what he calls the Cobble Hill Antipsychotic and Behavior Program, Dr. Mudannayake has spearheaded a multidisciplinary effort aimed at evaluating and minimizing the use of antipsychotics among Cobble Hill residents with dementia. …