Reply to “Response to Dr. Ouslander's Editorial on Antipsychotic Use in Nursing Home Residents”

Abstract

I appreciate and respect Dr. Cohen-Mansfield's comments [1] on my editorial discussing the use of antipsychotics in nursing home residents [2]. She is a passionate advocate for nursing home residents with dementia and behavioral symptoms, and she has contributed seminal research to this critical and challenging area of clinical Geriatrics practice.

I agree with many of her comments. Antipsychotics have been frequently used inappropriately and have served as “chemical restraints” among nursing home residents with dementia for many decades. Antipsychotics are not benign drugs and have many potentially severe adverse effects including an association with increased mortality that has resulted in black box warnings for their use, as illustrated in Figure 1 of my editorial. Thus, the risks of these adverse effects must be carefully weighed against the potential benefits for individual nursing home residents. I also agree that there has been considerable research demonstrating the benefits of a variety of non-pharmacological interventions. These interventions should be used as the treatment of first choice for nursing home residents with dementia and bothersome behavioral symptoms. The challenge, however, is that low staffing levels and related time constraints in many nursing homes complicate the feasibility of using them. Moreover, training nursing home staff members to perform some of these interventions can be time consuming due to high nursing home staff turnover, and many nursing home staff does not have the background and education that are required for effectively implementing the non-pharmacological strategies while being responsible for other aspects of care for residents with disruptive behaviors. It would be ideal to have multiple staff members with Teepa Snow's abilities [3], but that is not realistic given the current staffing situation in many US nursing homes.

I do, however, strongly disagree with some of Dr. Cohen-Mansfeld's assertions. First, she does not consider the clinical scenarios I used, including the one involving my own mother, delusions. They were in fact delusions as defined by the DSM-5-TR: “fixed beliefs that are not amenable to change in light of conflicting evidence.” [4] More importantly, she states “…the use of antipsychotic medications for individuals with dementia who do not have a prior diagnosis of schizophrenia constitutes an inhumane chemical restraint in all, or at least most, cases.” This is a blanket statement that illustrates naivete about the realities of clinical practice and the provision of person-centered care—which in my view is the essence of caring for older people [5]. I stand by my recommendations and believe that the vast majority of experienced geriatricians and geropsychiatrists who practice clinical Geriatrics would agree with them: IF a nursing home resident/patient is in fact psychotic (including paranoid delusions), underlying medical conditions have been excluded, non-pharmacologic interventions have been attempted and failed, the behaviors present a danger to themselves or others, make essential care feasible to perform, and/or result in major declines in function and quality of life, THEN the judicious use and monitoring of an antipsychotic IS an appropriate medical intervention, and not a chemical restraint.

The author is solely responsible for the content of this editorial.

The author declares no conflicts of interest.

This publication is linked to a related editorial by Jiska Cohen-Mansfield. To view this article, visit https://doi.org/10.1111/jgs.19404.