A new study from the Journal of the American Medical Association concludes that the highly touted National Campaign to Improve Dementia Care has not accelerated a pre-existing decrease in the use of psychotropic drugs in nursing homes. In other words, the small decrease in psychotropic drug use in nursing homes to sedate and subdue residents might have occurred anyway, without the tens of thousands of hours that individuals and groups have spent pursuant to the Campaign in the last six years.
The study looked at the use of all psychotropic drugs on residents with dementia, in contrast to the Campaign, which focuses on antipsychotics while ignoring other classes of psych drugs despite their misuse on residents with dementia. After reviewing psych drug use for the three years prior to the Campaign and the three years after, the study’s authors found psych drug use was declining before the Campaign and continued to decline after, but at a lower rate. This was true even for antipsychotics which, again, were the focus of the Campaign. Use of one class of psych drugs, mood stabilizers, actually experienced an increase, probably because use is not measured by the Centers for Medicare and Medicaid Services (CMS). Thus, it is the easiest chemical restraint drug to hide from regulators. (One popular mood stabilizer, Depakote, is easy to hide from residents too. It comes in a sprinkle form that can be easily hidden in a resident’s food or drink.)
The timing of the study is interesting as the nursing home industry has so recently defended the success of the Campaign in response to a damning report from Human Rights Watch. The reported success they cite relies on a very narrow and very flawed measure of antipsychotic use that the study’s authors indicate is an “inadequate proxy for quality of care.”
CANHR believes the Campaign to Improve Dementia Care has had some value. Tens of thousands of nursing home staff have been trained about good dementia care and a great deal of resources have been utilized to promote non-drugging options to address the unmet needs of residents with dementia. The data, however, point to a totally ineffective Campaign: the overall rate of psychotropic drug use on nursing home residents has gone from 63.9% in 2012 to 63.1% in 2017.
Marginally successful or not, the Campaign represents a tragically missed opportunity. From the outset, CANHR and other resident advocates criticized the CMS emphasis on carrots (training and education) and near-total exclusion of sticks (citations and fines, i.e., enforcement) as the centerpiece of the Campaign. As a result, good nursing homes interested in doing better responded and lowered their use of chemical restraints. Bad facilities, however, have been free to ignore the Campaign entirely and are using more drugs to restrain residents than ever before.
According to recent CMS data, less than 0.5%(!) of nursing home deficiencies for unnecessary use of psych drugs are considered harmful for residents. Until we make the shift to understanding that chemically restraining a human being is every bit as harmful as physically restraining them, the Campaign will continue to spin its wheels in the mud of misleading data and feeble vision.