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

Abstract

My esteemed colleague, Dr. Joseph G. Ouslander, MD, has written a thought-provoking editorial [1] with which I respectfully disagree. Specifically, I take issue with his statements: “For some nursing home residents, not just those who have a well-documented exclusionary diagnosis, antipsychotics can be an essential therapeutic intervention,” and “Here is the rub: some of these individuals are in fact psychotic, and the use of antipsychotics IS appropriate to prevent danger to themselves or others, to make essential care feasible to perform, to treat intense psychological distress, and to prevent major declines in function and quality of life.”

Dr. Ouslander illustrates his points with an example of a patient “admitted from the hospital with moderately advanced dementia and residual delirium who was verbally agitated and resisting care because she wanted to see her mother.” According to his description, she said something to the effect of, “… the people who work here killed her and now they want to kill me.” This, however, is NOT a clear example of a patient in whom antipsychotic use would be appropriate, nor is “paranoid delusions” the correct diagnosis [2, 3]. A person with moderately advanced dementia, recently transferred from the hospital, is likely to have difficulty articulating her perception of the situation. The words she used were the only means at her disposal to convey her sense of being endangered, scared, and alone. Rather than resorting to antipsychotic medication, this patient needs reassurance that she is being cared for and that staff members will be doing everything possible to make her comfortable. A female staff member, speaking in a soft, calm voice, should attempt to comfort her, offering light physical touch—if the patient is open to it—and providing a drink or other calming gestures. Non-threatening, compassionate care should be the response, not the administration of an antipsychotic medication that could expose her to potential harmful side effects.

There are many other ways to soothe persons like this woman, including visual, vocal, musical, verbal, and physical approaches, as well as social and recreational activities. After patience and attention are devoted to her comfort, she is likely to begin to experience a decline in her sense of danger and to reframe her expression thereof. A case study by Cohen-Mansfield and Parpura-Gill (2007) [4] offers an illustrative example.

Another “proof” favoring this non-pharmacological approach is the other example in Dr. Ouslander's editorial, which involves a resident referred to as “Mama O,” who, 2 days after admission to a nursing home for postsurgical rehabilitation, became extremely agitated, scratching and hitting staff members during routine care. Mama O reportedly said, “… last night the police came in and took me to the basement and assaulted me. I'm afraid they will do it again.” This, again, is not a delusion but rather a way for a person with impaired short-term memory to express her distress and fear of further pain in an unfamiliar and painful situation. As Dr. Ouslander later noted, after he engaged with Mama O, she calmed down, and her “delusion” did not recur. This incident further supports the argument that antipsychotic medication is not the solution to situations of this nature. What Mama O needed was someone to listen, understand her distress and fear, and respond with empathy.

So, are antipsychotics in nursing home residents with dementia a chemical restraint or an essential therapeutic intervention? They are often chemical restraints—used to compensate for clinical staff's lack of training, time, and tools to address residents' emotional needs. Such residents are not psychotic. They are trying, in the best way they can, to cope with limitations imposed by cognitive decline and to express very real feelings of fear, isolation, pain, and despair. Many facilities lack appropriate preventive activities and stimuli that promote a sense of community, warmth, and meaningful engagement, which could mitigate some of these behaviors.

Furthermore, clinical staff often overlook other potential causes of agitation, such as undiagnosed pain. The editorial refers to pain as a cause of agitated behaviors, citing Husebo et al. 2011 [5]. The Husebo study followed prior findings that not only demonstrated a link between behavioral challenges and pain, but also found that physicians often missed that pain. A more accurate assessment of pain was found to have been provided by nursing assistants who were responsible for ADL care, most likely because they have much more exposure than physicians to the person with dementia during potentially painful experiences [6].

Geriatric institutions require clinicians who are skilled in empathy, interpreting the emotions behind residents' outbursts, and calming those who are distressed. Academic departments specializing in dementia care are needed to train experts who can work in settings that provide care for individuals with dementia. These clinicians can add critical expertise to nursing home teams, which too often resort to physicians or psychiatrists who prescribe antipsychotics before less invasive interventions have been sufficiently explored. Such experts can guide staff in providing more humane and appropriate responses to the challenges of dementia care.

In my view, 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. For those who are already receiving such medications, multiple studies—not just one or two—demonstrate the feasibility and safety of discontinuing antipsychotic drugs without adverse effects [7-13]. These studies should serve as the basis for establishing a new standard of care for the use of antipsychotics and similar medications.

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

The author has nothing to report.

The author declares no conflicts of interest.

This publication is linked to a related reply by Joseph G. Ouslander. To view this article, visit https://doi.org/10.1111/jgs.19399.