Yesterday Human Rights Watch (HRW) issued “They Want Docile”, a report critical of antipsychotic medications for the off-label treatment of dementia. Although the report is receiving media attention from outlets such as CNN, it is not exactly a revelation as the US Department of Health and Human Services published similar findings about antipsychotics back in 2011.
HRW asserts that we have a big problem and that our government should fix it, mostly with changes that will cost the government more money. Both assertions are false. We have a small problem with better solutions than government intervention.
So as not to reinvent the wheel in this post, in 2011 CNN ran an article with compelling counterpoints, namely that off-brand application does not mean bad or ineffective.
Although Medicare reimbursement is a separate issue, off-label prescriptions solve a host of medical conditions and off-label use of antipsychotic medications for dementia symptoms is widely recommended by a plethora of authorities such as the American Psychiatric Association and Alzheimer’s Association. In the HRW study this point is buried in footnote #59 of 327, a point which arose neither in the study summary nor in articles that cite it such as yesterday’s CNN article linked to above.
Nonconsent is a complicated issue, acknowledged by the HRW report as outside it’s scope. The numbers would likely bear out that the vast majority of patients addressed by the HRW report who receive antipsychotic medications have been diagnosed as having cognitively lost their capacity for their own healthcare decisions. As such, the question is then better framed as: What are the costs and benefits of informed and free consent by appointed health care decision makers where physicians have already prescribed antipsychotic medications?
The HRW report provides anecdotal evidence of nonconsent, but not statistical. Before jumping to conclusions about more government funding, research and statistics need to answer questions such as: What is the frequency with which antipsychotic medications are prescribed for dementia symptoms where medical and environmental interventions have not been reasonably exhausted? When this occurs, what is the frequency where consent is not obtained? When not obtained (or where refused) what are the reasonable alternatives to antipsychotic medications? Where interventions have been exhausted and alternatives do not exist, does consent become merely an academic exercise?
One solution proposed by HRW is additional staff, though the HRW report includes data that more staff will not necessarily result in better outcomes. The primary current dynamic in effective senior care is the unavailability of a labor force to care for our aging population. Would our aging population benefit from more caregivers and better staffing ratios for the purpose of reducing the use of antipsychotic medications? Although there is mixed data, the answer is probably Yes. Would the benefit be so great that already unbalanced federal and state budgets should shift resources for this purpose at the expense of other non-medical institutionalization (such as assisted living), home-based programs, low-income seniors, or the myriad other budget priorities? Probably not.
The HRW report makes worthy recommendations to strengthen enforcement of existing regulatory requirements related to care planning. Sufficient care planning and implementation contributes towards exhausting nonpharmaceutical interventions.
Additionally, HRW should be applauded for the reminder to avoid a culture of excessive medication, and that environmental and medical interventions should be explored first.
In sum, excessive utilization of antipsychotic medications for dementia is a problem, but from a pragmatic approach it is not due to off-brand use or absence of consent. The problem most frequently arises from inattention to alternative interventions. Heavy hammers such as new government regulations and spending will not produce outcomes that surpass the existing tools in our toolkits such as blood and urine tests, correct diagnosis of behavioral symptoms, trained and motivated caregivers, appropriate physical environments, and engaging activities.