That’s Not What We Said

TO THE EDITOR:

Keys and DeWald¹ published a review in Annals of Long-Term Care: Clinical Care and Aging recently, and discussion followed in Letters to the Editor in June. In reply to comments by Mark H. Beers, MD, Keys and DeWald stated, “On the other side, the Federal Nursing Home Reform Act, or OBRA ’87, developed clear guidelines and indications for the use of antipsychotic medications in nursing home settings, including indications for psychotic and behavioral symptoms associated with dementia.”

As the author of these Guidelines to Surveyors for the Use of Antipsychotic Medications in Nursing Homes (hereinafter, Guidelines) (Dr. Kidder) and co-chairs of a multi-organizational panel that gave input into their development (Drs. Levinson and Smith), we would like to say, “That is not what we said.”

These Guidelines were for surveyors (see title), not prescribers, and were designed to cause citation of a nursing facility if that facility did not by some mechanism prevent an attending physician from gross misprescription of an antipsychotic medication to a nursing facility resident with dementia. At the time the Guidelines were created, as now, no antipsychotic carried an FDA-approved indication for the treatment of psychosis associated with dementia or behavioral symptoms associated with dementia. Many on the panel believed that these medications should only be used to correct hypothesized neurochemical abnormalities that, in turn, can cause behavioral symptoms, but that behavioral symptoms do not by themselves justify prescription. The Guidelines, however, did allow prescription of antipsychotics to residents with dementia if that behavior made the resident a danger to themselves or others. In the absence of evidence one way or another about efficacy in that situation, the Guidelines did not direct surveyors to cite such usage. But, the Guidelines did not encourage or validate this practice either. These Guidelines were not comprehensive in listing all contraindications. For example, the Guidelines do not include a barrier to the use of a typical antipsychotic in a resident with dementia with Lewy bodies or one with known hypersensitivity to a certain drug. The Guidelines define certain clinical situations in which surveyors could determine that prescription of these medications was always incorrect, particularly to target a common practice of that time of using these medications as “chemical restraint” rather than a bona fide approach to treatment of psychopathology.

The Guidelines cannot be viewed as a permission or validation of the practice of prescribing antipsychotic medications, typical or atypical, to demented residents. Such regulations reflect a minimum standard. It is critical to the autonomy of the medical profession to understand that federal and state guidelines for surveyors and regulations do not define standard of care, let alone state-of-the-art care. Instead, they reflect minimum standards of medical care. The definition of standard care and continuing evolution of state-of-the-art care is the domain of the medical profession.

David A. Smith, MD, FAAFP, CMD
Professor of Family Medicine, Texas A&M University, Brownwood, TX

Samuel W. Kidder, PharmD, MPH
Independent Pharmacy Consultant Silver Spring, MD

Reference

1. Keys MA, DeWald C. Clinical perspective on choice of atypical antipsychotics in elderly patients with dementia, Part II. Annals of Long-Term Care: Clinical Care and Aging 2005;13(3):30-38.

The authors thank Drs. Smith and Kidder for providing this insightful and clarifying information.