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The Harm in Prioritizing Policy Over Patients

By Andy Rosenzweig, MD

The term “nursing home” conjures up different images for different people. Some people picture active older adults playing bridge and doing water aerobics. Others have visions of wheelchair-bound, elderly who have more severe challenges. 

The capacity of nursing home residents varies greatly, it’s true. But the dark days of overmedicating residents whose conditions, like Alzheimer’s disease, cause them delusions or hallucinations have mostly become a thing of the past. For a time, “difficult” patients were given antipsychotics to calm them down and ease the burden of care on staff. It was happening too often, and it wasn’t right. 

Federal regulators stepped in, as they should have. They set up a system to gradually reduce the dose of psychotropic medications, which include antipsychotics, for long-term care residents. That included defining how much was too much and providing guidance on stepping residents down to lower levels of antipsychotics – or off them altogether. It was a difficult but necessary task. 

But their guidance can be difficult to apply for some residents. For example, up to 40% of Parkinson’s disease patients are more likely to experience more frequent and more extreme psychosis as their disease progresses. Reducing or completely eliminating antipsychotics that can help manage those ongoing symptoms may not be responsible health care for these patients.

This leaves nursing homes stuck between trying to do right by patients and trying to follow the letter of the regulation. The penalties for not adhering are severe. Having too many residents on antipsychotics, even at low levels, could keep a nursing home from earning a coveted 5-star rating.

Federal regulators’ intentions were noble. Chemically restraining patients is not appropriate. But their current policy disregards the value of patient-centered care for patients living with psychiatric conditions. Changing patients’ antipsychotic medication should be based on their symptoms, demeanor, their history with prior attempts to reduce dose and the risk they pose to others, as well as family input. It should not be based on a one-size-fits-all federal policy. 

I coach nursing homes on how to find patients’ appropriate dosage and remain compliant. It’s an onerous process for staff, but there are ways to document why certain patients should remain on an antipsychotic, yet too often nursing homes aren’t sure how. Instead, they err on the side of caution. But playing it safe has the potential to keep patients from accessing forthcoming – and potentially lifechanging – medications for dementia, agitation and aggression.  

There’s more than one way to help patients in long-term care facilities. Just as regulators moved to stop overmedication, they should also limit unnecessary or overly broad regulations and instead focus on allowing patients to get the care that’s right for them.

Andy Rosenzweig, MD, is the Chief Medical Officer of a telepsychiatry company and a member of the Alliance for Patient Access.

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