"Use of antipsychotic drugs raises alarm; Federal data obtained by the Globe show many nursing homes make heavy use of antipsychotic drugs to pacify residents" by Kay Lazar and Matt Carroll | Globe Staff April 29, 2012
Many nursing homes that have commonly used antipsychotic drugs to control agitation and combative behavior in residents who should not be receiving the powerful sedatives, exposing them to the risk of dangerous side effects....
The situation is alarmingly common in Massachusetts and across the nation, a Globe investigation has found....
The drugs, which are intended to treat severe mental illness such as schizophrenia, can leave people in a stupor. The US Food and Drug Administration has issued black-box warnings - the agency’s most serious medication alert - about potentially fatal side effects when antipsychotics are taken by patients with dementia.
Nursing home regulators have for years collected data about individual homes’ use of antipsychotics but have not publicly released facility-specific information, citing patient privacy concerns. The government finally provided the data to the Globe, 19 months after the newspaper submitted a Freedom of Information Act request.
The data show that in more than one in five nursing homes in the United States, antipsychotics are administered to a significant percentage of residents despite the fact that they do not have a psychosis or related condition that nursing home regulators say warrants their use. The proportion of homes using antipsychotic drugs in this fashion is even higher in Massachusetts....
Physicians have wide latitude to prescribe drugs, even for purposes not approved by the FDA or recommended by the federal agency that regulates nursing homes, the Centers for Medicare & Medicaid Services.
Still, both agencies say it’s not appropriate in most cases for patients suffering from dementia to be prescribed antipsychotics. The medications increase the risk of lethal infections and cardiovascular complications in these elderly patients, the FDA says. In addition, the drugs can cause dizziness, a sudden drop in blood pressure, abnormal heart rhythms, blurred vision, and urinary problems.
Dr. Michael Gloth, a Johns Hopkins University School of Medicine associate professor who specializes in the care of elderly patients, said antipsychotics have not been thoroughly studied in the types of residents typically found in nursing homes - elderly people with several illnesses who are taking multiple medications. But the limited data suggest they can be dangerous, he said.
“We have an inordinate amount of prescriptions written for a population that is already frail, and we know these drugs increase the risk for side effects, including death,’’ Gloth said. “So why are they being written?’’
I'll give you one gue$$.
Nursing home administrators counter that they sometimes must use antipsychotics to keep aggressive residents from harming themselves, other residents, or staff - the fog of dementia can cause people to punch, kick, or shove others.
The administrators say the government data exaggerate the problem of antipsychotic abuse because the numbers include patients on low doses that facilities are trying to wean off the medications.
“There are things out there the industry can do better, there is no question about that, but there are good things in the industry that are not seen because of these issues with the statistical data,’’ said Frank Grosso, vice president of pharmacy services at Genesis HealthCare, which owns 202 nursing homes in 13 states, including Massachusetts.
Many industry executives also complain that federal rules governing the drugs’ use are contradictory, and that nursing home regulations listing conditions that can be treated with antipsychotics were written about 20 years ago and weren’t updated when the FDA more recently approved two other mental illnesses - including bipolar disorder - for treatment with some of the drugs.
The government data reviewed by the Globe show that despite the industry’s complaints, antipsychotic overuse is prevalent....
Two years ago, the Globe reported that Massachusetts was among the states with the highest percentage of nursing home residents receiving antipsychotics for conditions not recommended by regulators....
See: The Massachusetts Model: Nursing Home Will Make You Nuts
Just living here does because the image collides with reality.
Federal regulators acknowledge industry complaints about the lack of clarity of some of their guidance. A manual used by nursing homes and state inspectors says in one place that antipsychotics may be considered for “dementing illnesses with associated behavioral symptoms,’’ but then says three pages later that the medications should not be used for many of the behavioral symptoms common in dementia, such as wandering, restlessness, and insomnia.
Changes will be made to the manual as part of the federal government’s larger campaign to improve dementia care in nursing homes, said Alice Bonner, the nation’s chief nursing home regulator who directs the nursing home division at the Centers for Medicare & Medicaid Services.
The agency is also working on updating its list of acceptable conditions for treatment with antipsychotics. Officials are leaning toward adding bipolar disorder to the list but taking off hallucinations, because it is such a “loose category’’ that invites overuse of the medications, said Edward Mortimore, who oversees analysis of nursing home data for the agency.
Federal rules give state inspectors authority to cite nursing homes if residents receive antipsychotics inappropriately. Until 2006, there was a specific citation for overuse of antipsychotics, but that year officials folded that citation into a more generic “unnecessary medication use’’ category that pertains to all medicines.
Bonner said her agency is considering reviving the specific citation for antipsychotic use to encourage more scrutiny, but is concerned that homes will instead use other sedating drugs that can also be harmful. “One of the things we want to do is to make sure that surveyors are looking out for a prescribing shift,’’ Bonner said. “Did a person get taken off of an antipsychotic and simply put on an antidepressant or antianxiety agent instead.’’
Some studies suggest that such changes are occurring, and that elderly dementia patients on antidepressants are at increased risk of falling....
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And once you kick the habit?
"Finding alternatives to potent sedatives; Nursing homes increasingly take new tack in dealing with dementia" by Kay Lazar | Globe Staff April 30, 2012
LITTLETON - Marjorie Bontempo was a changed woman after moving into Life Care Center of Nashoba Valley, a Littleton nursing home where the staff doesn’t believe in using antipsychotic drugs simply to calm residents.
A physician had prescribed an antipsychotic for Bontempo a year earlier, after Alzheimer’s disease had transformed her from an accomplished seamstress and demure family peacekeeper into a cantankerous, confused woman who refused to eat. The medicine eased her aggression but left her dazed, said her daughter, Patty Sinnett.
How do you know that is dementia because I run across old women who are like that all the time?
Nashoba’s nurses took Bontempo off the powerful sedative. Sinnett went to visit soon after and found her mother in the activity room watching a Clark Gable movie.
“She started explaining the whole movie to me, like a normal person would,’’ Sinnett said. “It was the first time I had had a conversation with her in a year. It was incredible.’’
I'm convinced this society is over-drugged, I mean, over-medicated.
The Littleton facility is one of a small but growing number of nursing homes that are treating the agitation and disruptive behavior that often accompany dementia without resorting to antipsychotics.
Instead, Life Care Center and similar homes try to tailor care to each resident, to make it familiar and comforting. Staffers comb residents’ pasts to learn their preferences, hobbies, and accomplishments, tapping bedrock emotions that endure long after memory fades.
The Globe reported Sunday that many homes still rely heavily on antipsychotics to deal with aggressive residents, though most of these residents do not have conditions that nursing home regulators say warrant use of the drugs. And federal authorities have warned of sometimes lethal side effects when antipsychotics are taken by elderly dementia patients.
Industry leaders say that the drugs must be used at times to protect residents and staff, and that many of the nondrug approaches being tried require specialized training that far too few nursing home workers have received, and often more staffing.
They note that drug regulators have not approved any medications specifically to manage the difficult behaviors exhibited by residents with dementia, and that physicians are allowed to prescribe antipsychotics “off-label’’ for conditions other than what they were designed for: serious mental illnesses such as schizophrenia.
Overall use of the drugs in nursing home patients without mental illnesses has declined since 2005, according to the Globe’s analysis of federal data....
From the circular layout of its Alzheimer’s unit - so residents don’t encounter a dead-end in a hallway, a potential source of stress for those who wander - to the goats and llamas grazing in its pastoral front yard, Nashoba stands out.
Executive director Ellen Levinson, whose two golden retrievers often greet visitors at the front door, said she has found that animals have a calming effect. The walls of the 27-bed Alzheimer’s unit are lined with animal pictures, and bird feeders hang from nearly every window.
A caretaker sometimes leads the llamas through the halls and into the Alzheimer’s unit, where even residents who relentlessly wander stop to pet the regal creatures.
Activities and care are matched to residents’ individual personalities and abilities....
Many of the residents are no longer able to speak, so their behaviors - tears, screams, slapping, smiles - are how they communicate....
Caring for people with dementia, without relying on antipsychotics, requires nursing home staffers to become detectives, said Paul Raia, vice president of clinical services for the Alzheimer’s Association of Massachusetts and New Hampshire.
Raia, who trains nursing home staffers in dementia care, encourages them to methodically chart difficult behaviors to pinpoint possible triggers. In one recent case, a male resident was inexplicably hitting others, but by tracking his actions, the nurses discovered that he struck only during the day, and only when he was in a certain section of a room.
“We learned the light hurt his eyes,’’ Raia said. “It was in a day room and all we had to do was draw the shades so the light wasn’t in his eyes, and it didn’t happen again.’’
How many places would just pre$cribe a pill?
Dr. Jonathan Evans, a medical director at two Virginia nursing homes, said he prescribed antipsychotics for years for dementia patients, often feeling pressure from overwhelmed staffers or agonized families who believed the medications would help their loved ones.
“We are trained as physicians to think that every problem has a potential solution, and the most widely used solution is a medication, but that doesn’t work for every problem,’’ said Evans, president-elect of the American Medical Directors Association, a national trade group for physicians who work in nursing homes.
Evans stopped prescribing antipsychotics for dementia patients after the government warnings of lethal side effects, and he said he will dedicate his presidency to educating other caregivers that challenging behaviors from dementia may be due to untreated pain from arthritis or an infection, or fear.
He has found that people with dementia often understand and respond better to nonverbal communication - a gentle approach at eye-level - than to words.
“These behaviors are often a primitive, biological response that is like a reflex,’’ said Evans, who also is a consultant to Life Care Centers of America, which operates more than 200 facilities in 28 states, including Nashoba.
Across the country, a variety of approaches have been developed to help nursing home staff better understand and manage difficult behaviors without using antipsychotics, but researchers are still trying to determine which methods work best.
Such drug-free approaches can be labor-intensive.
Somehow we always have enough money for wars, Wall Street, and Israel.
The Globe’s analysis found a link between staffing levels in nursing homes and the use of antipsychotics. Those with the highest percentage of residents who receive antipsychotics contrary to nursing home regulators’ recommendations also tend to have the lowest numbers of registered nurses and nurses aides.
These homes also typically have more residents on Medicaid, a government insurance program that reimburses nursing homes at a far lower rate for patient care than private insurers do, so the homes would have less money to hire staff.
Half of the residents in Nashoba’s Alzheimer’s unit have private insurance, which means the facility is receiving $412 daily for each of these residents, compared with the $184 daily rate for the other patients, whose care is covered by Medicaid, according to Levinson, the executive director.
That allows Nashoba the luxury of higher staffing levels than the state median, according to the Globe’s analysis.
“Money helps with staffing,’’ said Levinson, the executive director, “but having the right philosophy is not expensive.’’
Nashoba does not accept residents who have a history of combative behaviors that could hurt other residents. That typically means that large, strong, aggressive men who are still able to walk are not allowed.
But even homes that take difficult dementia patients, such as Beatitudes Campus in Phoenix, have been able to reduce their reliance on antipsychotics....
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Also see: Nursing Home Profits
The treatment of America's elderly is a national disgrace and scandal.
