C International Psychogeriatric Association 2014 International Psychogeriatrics (2014), 26:3, 361–362 doi:10.1017/S1041610213002597
C O M M E N TA R Y PA P E R O F T H E M O N T H
Dementia care in nursing homes: a golden opportunity The paper by Kleijer and colleagues (2014) in this issue of International Psychogeriatrics describes factors that may influence antipsychotic drug (APD) prescribing rates in nursing homes in several countries. The authors conclude that the large variability is only partly explained by differences in resident characteristics, and that it is associated with certain facility characteristics such as bed size and urban/rural location. They also identify the likelihood that differences in physician prescribing patterns or facility prescribing culture may influence APD prescribing rates, as has been found in previous studies (Briesacher et al., 2005; Chen et al., 2010). The authors point out a number of limitations in this study: small sample size limiting generalizability; questionable data accuracy on some RAI/MDS 2.0 items; inability to distinguish high versus low APD dosage or pro re nata (PRN) use; and crosssectional design. And while they ascertain that “little research has been done into factors associated with this variability,” the authors do reference several prior studies that address at least some potential factors. Research reports by Castle et al. (2009) and Crystal et al. (2009), which examined this issue, were not mentioned. As the researchers and others have noted, the availability of non-pharmacological approaches, training of nurses and direct care workers (DCWs), and availability of robust activity programs are all factors that may lead to lower prescribing rates. Nursing homes that have embraced culture change and person-centered care (Brownie, 2011; O’Neil et al., 2011) and small house models (Grabowski, 2011) have generally demonstrated lower APD use. But more research is needed to understand how implementation of these transformative models may alter physician prescribing practices and other variables. Moving away from a medical model of nursing home care will require new measures of how we care for people with dementia. Measuring concepts such as person-centered care and culture change are challenging but important – new instruments to measure various aspects of dementia care are currently being designed and tested (White et al., 2008; Edvardsson et al., 2009; Gitlin et al., 2012). The purpose of generating new knowledge is to translate it to settings where clinicians can use
evidence to change practice in meaningful ways. We may not learn enough in small, cross-sectional, or descriptive studies to be able to determine effective interventions to reduce unnecessary prescribing of APDs. Given the state of the science, we need comparative effectiveness research (CER): randomized controlled trials with adequate power to detect differences between various interventions, for example, physician education through academic detailing (Avorn et al., 1992) versus implementation of training programs on non-pharmacological approaches to dementia care (Gitlin et al., 2012; Wehry, 2012). We also need to examine laws and regulations in different countries to determine whether various regulatory approaches to oversight and enforcement are associated with differences in APD use. Studies in the United States suggest that state-to-state variability in citation and enforcement patterns may be associated with differences in behavioral healthcare (Castle et al., 2007; Bowblis et al., 2012). The authors make the point that in many countries, rates of APD use in people with dementia living in nursing homes are high nationally, despite a documented lack of efficacy of these drugs in this population (Kleijer et al., 2014). This presents a golden opportunity for the international dementia care community to come together and actively promote and test personcentered, individualized solutions and new models of nursing home care. Physicians, psychiatrists, nurses, social workers, advocates, therapists, activity professionals, government agencies, and most importantly residents and families must all work together to transform dementia care in nursing homes. We must identify, implement, and evaluate new approaches and workforce practices that support DCWs and inter-professional teams. Through implementation and active dissemination of translational research, we will be able to build the evidence-base needed to drive improvements in quality of care and quality of life for people living in nursing homes. ALICE BONNER School of Nursing, Northeastern University Boston, Massachusetts, USA Email: [email protected]
362
A. Bonner
References Avorn, J. et al. (1992). A randomized trial of a program to reduce the use of psychoactive drugs in nursing homes. New England Journal of Medicine, 327, 168–173. Bowblis, J. R., Crystal, S., Intrator, O. and Lucas, J. A. (2012). Response to regulatory stringency: the case of antipsychotic medication use in nursing homes. Health Economics, 21, 977–993. doi:10.1002/hec.1775. Briesacher, B. A. et al. (2005). The quality of antipsychotic drug prescribing in nursing homes. Archives of Internal Medicine, 165, 1280–1285. doi:10.1001/archinte. 165.11.1280. Brownie, S. (2011). A culture change in aged care: the Eden alternative. Australian Journal of Advanced Nursing, 29, 63–68. Castle, N. G., Engberg, J. and Men, A. (2007). Variation in the use of nursing home deficiency citations. Journal for Healthcare Quality, 29, 12–23. Castle, N. G., Hanlon, J. T. and Handler, S. M. (2009). Results of a longitudinal analysis of national data to examine relationships between organizational and market characteristics and changes in antipsychotic prescribing in US nursing homes from 1996 through 2006. American Journal of Geriatric Pharmacotherapy, 7, 143–150. doi:10.1016/j.amjopharm.2009.05.001. Chen, Y., Briesacher, B. A., Field, T. S., Tjia, J., Lau, D. T. and Gurwitz, J. H. (2010). Unexplained variation across US nursing homes in antipsychotic prescribing rates. Archives of Internal Medicine, 170, 89–95. doi:10.1001/ archinternmed.2009.469.
Crystal, S., Olfson, M., Huang, C., Pincus, H. and Gerhard, T. (2009). Broadened use of atypical antipsychotics: safety, effectiveness, and policy challenges. Health Affairs (Millwood), 28, w770–w781. doi:10.1377/hlthaff.28.5.w770. Edvardsson, D., Sandman, P. O. and Rasmussen, B. (2009). Construction and psychometric evaluation of the Swedish language Person-Centred Climate Questionnaire – staff version. Journal of Nursing Management, 17, 790–795. doi:10.1111/j.1365-2834.2009.01005.x. Gitlin, L. N., Kales, H. C. and Lyketsos, C. G. (2012). Nonpharmacologic management of behavioral symptoms in dementia. JAMA, 308, 2020–2029. doi:10.1001/jama. 2012.36918. Grabowski, D. C. (2011). Comparing the Green House Model with Traditional Nursing Homes on Cost and Quality of Care. Princeton, NJ: Robert Wood Johnson Foundation. Kleijer, B. C. et al. (2014). Variability between nursing homes in prevalence of antipsychotic use in patients with dementia. International Psychogeriatrics, 26, 363–371. O’Neil, M., Freeman, M., Christensen, V., Telerant, A., Addleman, A. and Kansagara, D. (2011). NonPharmacological Interventions for Behavioral Symptoms of Dementia: a Systematic Review of the Evidence. VA-ESP Project #05-225 Report; 2011, Portland, OR. Wehry, S. (2012). Oasis 1.3 Training Manual (Massachusetts Senior Care, CMS Partnership Initiative to Improve Dementia Care). Montpelier, VT: Vermont Health Care Association. White, D. L., Newton-Curtis, L. and Lyons, K. S. (2008). Development and initial testing of a measure of person-directed care. Gerontologist, 48, 114–123.
C O M M E N TA R Y PA P E R O F T H E M O N T H
Dementia care in nursing homes: a golden opportunity The paper by Kleijer and colleagues (2014) in this issue of International Psychogeriatrics describes factors that may influence antipsychotic drug (APD) prescribing rates in nursing homes in several countries. The authors conclude that the large variability is only partly explained by differences in resident characteristics, and that it is associated with certain facility characteristics such as bed size and urban/rural location. They also identify the likelihood that differences in physician prescribing patterns or facility prescribing culture may influence APD prescribing rates, as has been found in previous studies (Briesacher et al., 2005; Chen et al., 2010). The authors point out a number of limitations in this study: small sample size limiting generalizability; questionable data accuracy on some RAI/MDS 2.0 items; inability to distinguish high versus low APD dosage or pro re nata (PRN) use; and crosssectional design. And while they ascertain that “little research has been done into factors associated with this variability,” the authors do reference several prior studies that address at least some potential factors. Research reports by Castle et al. (2009) and Crystal et al. (2009), which examined this issue, were not mentioned. As the researchers and others have noted, the availability of non-pharmacological approaches, training of nurses and direct care workers (DCWs), and availability of robust activity programs are all factors that may lead to lower prescribing rates. Nursing homes that have embraced culture change and person-centered care (Brownie, 2011; O’Neil et al., 2011) and small house models (Grabowski, 2011) have generally demonstrated lower APD use. But more research is needed to understand how implementation of these transformative models may alter physician prescribing practices and other variables. Moving away from a medical model of nursing home care will require new measures of how we care for people with dementia. Measuring concepts such as person-centered care and culture change are challenging but important – new instruments to measure various aspects of dementia care are currently being designed and tested (White et al., 2008; Edvardsson et al., 2009; Gitlin et al., 2012). The purpose of generating new knowledge is to translate it to settings where clinicians can use
evidence to change practice in meaningful ways. We may not learn enough in small, cross-sectional, or descriptive studies to be able to determine effective interventions to reduce unnecessary prescribing of APDs. Given the state of the science, we need comparative effectiveness research (CER): randomized controlled trials with adequate power to detect differences between various interventions, for example, physician education through academic detailing (Avorn et al., 1992) versus implementation of training programs on non-pharmacological approaches to dementia care (Gitlin et al., 2012; Wehry, 2012). We also need to examine laws and regulations in different countries to determine whether various regulatory approaches to oversight and enforcement are associated with differences in APD use. Studies in the United States suggest that state-to-state variability in citation and enforcement patterns may be associated with differences in behavioral healthcare (Castle et al., 2007; Bowblis et al., 2012). The authors make the point that in many countries, rates of APD use in people with dementia living in nursing homes are high nationally, despite a documented lack of efficacy of these drugs in this population (Kleijer et al., 2014). This presents a golden opportunity for the international dementia care community to come together and actively promote and test personcentered, individualized solutions and new models of nursing home care. Physicians, psychiatrists, nurses, social workers, advocates, therapists, activity professionals, government agencies, and most importantly residents and families must all work together to transform dementia care in nursing homes. We must identify, implement, and evaluate new approaches and workforce practices that support DCWs and inter-professional teams. Through implementation and active dissemination of translational research, we will be able to build the evidence-base needed to drive improvements in quality of care and quality of life for people living in nursing homes. ALICE BONNER School of Nursing, Northeastern University Boston, Massachusetts, USA Email: [email protected]
362
A. Bonner
References Avorn, J. et al. (1992). A randomized trial of a program to reduce the use of psychoactive drugs in nursing homes. New England Journal of Medicine, 327, 168–173. Bowblis, J. R., Crystal, S., Intrator, O. and Lucas, J. A. (2012). Response to regulatory stringency: the case of antipsychotic medication use in nursing homes. Health Economics, 21, 977–993. doi:10.1002/hec.1775. Briesacher, B. A. et al. (2005). The quality of antipsychotic drug prescribing in nursing homes. Archives of Internal Medicine, 165, 1280–1285. doi:10.1001/archinte. 165.11.1280. Brownie, S. (2011). A culture change in aged care: the Eden alternative. Australian Journal of Advanced Nursing, 29, 63–68. Castle, N. G., Engberg, J. and Men, A. (2007). Variation in the use of nursing home deficiency citations. Journal for Healthcare Quality, 29, 12–23. Castle, N. G., Hanlon, J. T. and Handler, S. M. (2009). Results of a longitudinal analysis of national data to examine relationships between organizational and market characteristics and changes in antipsychotic prescribing in US nursing homes from 1996 through 2006. American Journal of Geriatric Pharmacotherapy, 7, 143–150. doi:10.1016/j.amjopharm.2009.05.001. Chen, Y., Briesacher, B. A., Field, T. S., Tjia, J., Lau, D. T. and Gurwitz, J. H. (2010). Unexplained variation across US nursing homes in antipsychotic prescribing rates. Archives of Internal Medicine, 170, 89–95. doi:10.1001/ archinternmed.2009.469.
Crystal, S., Olfson, M., Huang, C., Pincus, H. and Gerhard, T. (2009). Broadened use of atypical antipsychotics: safety, effectiveness, and policy challenges. Health Affairs (Millwood), 28, w770–w781. doi:10.1377/hlthaff.28.5.w770. Edvardsson, D., Sandman, P. O. and Rasmussen, B. (2009). Construction and psychometric evaluation of the Swedish language Person-Centred Climate Questionnaire – staff version. Journal of Nursing Management, 17, 790–795. doi:10.1111/j.1365-2834.2009.01005.x. Gitlin, L. N., Kales, H. C. and Lyketsos, C. G. (2012). Nonpharmacologic management of behavioral symptoms in dementia. JAMA, 308, 2020–2029. doi:10.1001/jama. 2012.36918. Grabowski, D. C. (2011). Comparing the Green House Model with Traditional Nursing Homes on Cost and Quality of Care. Princeton, NJ: Robert Wood Johnson Foundation. Kleijer, B. C. et al. (2014). Variability between nursing homes in prevalence of antipsychotic use in patients with dementia. International Psychogeriatrics, 26, 363–371. O’Neil, M., Freeman, M., Christensen, V., Telerant, A., Addleman, A. and Kansagara, D. (2011). NonPharmacological Interventions for Behavioral Symptoms of Dementia: a Systematic Review of the Evidence. VA-ESP Project #05-225 Report; 2011, Portland, OR. Wehry, S. (2012). Oasis 1.3 Training Manual (Massachusetts Senior Care, CMS Partnership Initiative to Improve Dementia Care). Montpelier, VT: Vermont Health Care Association. White, D. L., Newton-Curtis, L. and Lyons, K. S. (2008). Development and initial testing of a measure of person-directed care. Gerontologist, 48, 114–123.
