Cutting Down on Antipsychotics

Over-Prescribed

CMS, the Centers for Medicare & Medicaid, announced in May that they are embarking on a multi-year initiative to cut the use of antipsychotic drugs in skilled nursing facilities by 15% by the end of this year. CMS cited statistics showing that nearly 40% of residents with dementia were getting antipsychotics even though they did not have a diagnosis supporting their use.

Other statistics from CMS indicate that in 2010 more than 17% of SNF residents received antipsychotic doses that were over the recommended levels.

“In 2013 we will set another goal,’’ said Alice Bonner, director of the nursing home division of CMS. “At that point, we will be looking at even more significant reductions.’’

CMS plans to achieve the cuts through training state inspectors and nursing home staff on alternatives to using antipsychotics for agitation and aggressive behaviors.  Participation in the reduction program is voluntary, but SNF trade groups pledged to work with CMS.

“We believe these antipsychotics are overprescribed,’’ said Dr. David Gifford, senior vice president of quality and regulatory affairs at the American Health Care Association, a SNF trade group. “Many clinicians, physicians, and family members believe these medications are useful and necessary, but data show otherwise.’’

This article was originally published in Pathways & Partners Newsletter - Issue 25.  To download this issue in PDF format, or past issues, visit our newsletter archives online at www.pathwayshealth.org/publications.

A Twist on Cultural Diversity

In the Bay Area, where diversity is the norm, caregivers often represent cultures from all over the world, while the residents they care for may be mostly white, Anglo-Americans whose only language is English.  Perhaps a look at Anglo-American culture will reveal ways to improve interactions between caregivers and residents.

In an ideal world, two people trying to communicate would each reach out to understand the other’s culture.  Realistically, residents may not be capable of learning about the caregiver’s culture to meet the caregiver halfway.  It defaults to the caregiver to bridge the gap.

Generalizations

Although no statement about someone in a particular culture holds true for all members of that culture, we can make useful generalizations that steer us in the right direction.  For example, Anglo-Americans tend to be:

• Time oriented and more rigid about times: 10:45 means exactly 10:45.
• Direct, with less socializing before getting down to business.
• Less formal, speaking and acting casually.
• In general, Anglo-Americans want to be pain-free and may not be as stoic as some other cultures.  They may ask for pain medication where a person from another culture might “tough it out.” 

Comfort zones

Anglo-Americans may be more open about discussing personal matters, illness, and dying than others. 

If a resident wants to talk about a subject that makes you uncomfortable, you may want to find someone else who might be able to interact with him more directly—perhaps someone from social services, a chaplain, or another caregiver.

Researchers have demonstrated that Anglo-Americans generally require a larger personal space around them—in other words, they don’t stand as close when talking as people of other cultures do.*  For instance, they may become uncomfortable and step back if they feel another person is standing too close.

Independence

Anglo-Americans as a whole tend to be more individually oriented and like control. They leave less to fate and want to direct their own lives. American law requiring informed consent is based on the principle of autonomy—freedom of choice for the individual.  In other cultures the family or physician may make decisions for a patient, whereas in the US the individual is considered more important to decision-making than the family. 

Many Anglo-Americans see themselves as having a pioneer spirit and prefer not to be dependent on their children for care or support, while in other cultures it is expected that older people will live with their adult children. 

Best practices

Whenever cultures differ there is plenty of room for misunderstandings.  Usually neither is right or wrong—just different.  The best practice for communicating smoothly is to ASK.  Ask family members or the resident about how things are done in their family.   People are usually grateful that you are asking and appreciate that you are trying to learn about how they like to do things.

*The New York Times, “In Certain Circles, Two Is a Crowd,” Nov. 16, 2006.

This article was originally published in Pathways & Partners Newsletter - Issue 25.  To download this issue in PDF format, or past issues, visit our newsletter archives online at www.pathwayshealth.org/publications.

Communicating with Residents

Be Heard Better

They are just little things, but they make a difference in reducing frustration for you and your residents.  We’re talking about techniques you can use every day to make communication smoother and more satisfying.

First let’s look at body position.  Standing over a resident who is sitting or in bed may feel threatening, especially if you are very close.  Research has shown that patients thought that their doctors stayed longer at the bedside than they actually did when the doctor sat down.  So try sitting down to appear less hurried. 

When people have hearing problems, as many older adults do, it is important to face the person directly and have your face at their eye level.  The shapes our lips make when speaking and expressions give residents a lot of clues to what we are saying.  It should go without saying that we should make sure hearing aides are in place, are turned on, and have fresh batteries.

Next we should speak slowly and clearly, enunciating our words precisely—slow down.  Older ears need more time to decipher what you are saying.  If you also have an accent, slowing down your speech will help older, hard-of-hearing adults understand you better.  It also helps to use gestures to supplement what you are saying.  For example, if you want the resident to sit in a chair, pat the chair or sit down to demonstrate what you would like.

By paying attention to the little details in our communications with the elderly, we can make the interchange more satisfactory for them and us!

This article was originally published in Pathways & Partners Newsletter - Issue 24.  To download this issue in PDF format, or past issues, visit our newsletter archives online at www.pathwayshealth.org/publications.