The paper by Kleijer and colleagues (2014) in this issue of International Psychogeriatrics describes factors that may influence antipsychotic drug (APD) prescribing rates in nursing homes in several countries. The authors conclude that the large variability is only partly explained by differences in resident characteristics, and that it is associated with certain facility characteristics such as bed size and urban/rural location. They also identify the likelihood that differences in physician prescribing patterns or facility prescribing culture may influence APD prescribing rates, as has been found in previous studies (Briesacher et al., Reference Briesacher2005; Chen et al., Reference Chen, Briesacher, Field, Tjia, Lau and Gurwitz2010).

The authors point out a number of limitations in this study: small sample size limiting generalizability; questionable data accuracy on some RAI/MDS 2.0 items; inability to distinguish high versus low APD dosage or pro re nata (PRN) use; and cross-sectional design. And while they ascertain that “little research has been done into factors associated with this variability,” the authors do reference several prior studies that address at least some potential factors. Research reports by Castle et al. (Reference Castle, Hanlon and Handler2009) and Crystal et al. (Reference Crystal, Olfson, Huang, Pincus and Gerhard2009), which examined this issue, were not mentioned.

As the researchers and others have noted, the availability of non-pharmacological approaches, training of nurses and direct care workers (DCWs), and availability of robust activity programs are all factors that may lead to lower prescribing rates. Nursing homes that have embraced culture change and person-centered care (Brownie, Reference Brownie2011; O’Neil et al., Reference O’Neil, Freeman, Christensen, Telerant, Addleman and Kansagara2011) and small house models (Grabowski, Reference Grabowski2011) have generally demonstrated lower APD use. But more research is needed to understand how implementation of these transformative models may alter physician prescribing practices and other variables.

Moving away from a medical model of nursing home care will require new measures of how we care for people with dementia. Measuring concepts such as person-centered care and culture change are challenging but important – new instruments to measure various aspects of dementia care are currently being designed and tested (White et al., Reference White, Newton-Curtis and Lyons2008; Edvardsson et al., Reference Edvardsson, Sandman and Rasmussen2009; Gitlin et al., Reference Gitlin, Kales and Lyketsos2012).

The purpose of generating new knowledge is to translate it to settings where clinicians can use evidence to change practice in meaningful ways. We may not learn enough in small, cross-sectional, or descriptive studies to be able to determine effective interventions to reduce unnecessary prescribing of APDs. Given the state of the science, we need comparative effectiveness research (CER): randomized controlled trials with adequate power to detect differences between various interventions, for example, physician education through academic detailing (Avorn et al., Reference Avorn1992) versus implementation of training programs on non-pharmacological approaches to dementia care (Gitlin et al., Reference Gitlin, Kales and Lyketsos2012; Wehry, Reference Wehry2012).

We also need to examine laws and regulations in different countries to determine whether various regulatory approaches to oversight and enforcement are associated with differences in APD use. Studies in the United States suggest that state-to-state variability in citation and enforcement patterns may be associated with differences in behavioral healthcare (Castle et al., Reference Castle, Engberg and Men2007; Bowblis et al., Reference Bowblis, Crystal, Intrator and Lucas2012).

The authors make the point that in many countries, rates of APD use in people with dementia living in nursing homes are high nationally, despite a documented lack of efficacy of these drugs in this population (Kleijer et al., Reference Kleijer2014). This presents a golden opportunity for the international dementia care community to come together and actively promote and test person-centered, individualized solutions and new models of nursing home care. Physicians, psychiatrists, nurses, social workers, advocates, therapists, activity professionals, government agencies, and most importantly residents and families must all work together to transform dementia care in nursing homes. We must identify, implement, and evaluate new approaches and workforce practices that support DCWs and inter-professional teams. Through implementation and active dissemination of translational research, we will be able to build the evidence-base needed to drive improvements in quality of care and quality of life for people living in nursing homes.