NURSING HOMES
OVER-PRESCRIBING ANTI-PSYCHOTICS

An alarming number of nursing home patients are receiving antipsychotic medications to sedate them or suppress disruptive behavior associated with dementia, even though the drugs are not approved for these uses, according to a recent report in the Wall Street Journal.

Nearly one-third of nursing home patients are on antipsychotic drugs, with a full 21 percent of occupants on the drugs without a diagnosis of psychosis. Some states are finding medication rates as high as 60 or 70 percent in some institutions.

Drug companies producing the most widely used antipsychotics—newer drugs called atypical antipsychotics—are reaping record profits, raking in nearly $12 billion in the past year. Federal reimbursements through Medicaid accounted for almost half the revenue—$5.4 billion in 2005—before the Part D drug benefit supplanted Medicaid coverage for people with Medicare and Medicaid in 2006. While 2006 profits were derived from a total of 45.4 million prescriptions, the illnesses these drugs were developed to treat, schizophrenia and bipolar disorder, afflict only seven million Americans. In recent years, Medicaid has spent more money on antipsychotic drugs than on any other class of pharmaceuticals -- including antibiotics, AIDS drugs or medicine to treat high-blood pressure.

Nursing homes often find it difficult to balance the demands of caring for certain patients against the pressure to keep staff costs down. The economics of elderly care can work in favor of drugs, because federal insurance programs reimburse more readily for pills than people.

The use of antipsychotic drugs comes amid a wider debate about how to care for the rising numbers of seniors, many of whom have behavior problems stemming from dementia. They can be difficult to manage, at home or in an institution. They can cry, lash out, wander or even be violent, to themselves or others. There aren't many effective methods to calm them, doctors say.
A big question is whether to use a medical model -- administering antipsychotics as the way to alleviate distressing symptoms of dementia -- or trying to find other ways to help these patients.

For example, in Massapequa, N.Y, a nursing home was recently fined by the state for injecting 90 doses of Haldol into a 96-year-old Alzheimer's patient. The woman, identified only as Resident #2, enjoyed listening to music and getting her nails polished, according to a state report. But when agitated, she banged her hand on the table and sometimes yelled. One aide found it was possible to calm her by offering ice cream and chatting with her, the report said. But other staff gave her the drug Haldol.

The use of atypical antipsychotic drugs in nursing homes continues despite scientific papers that question the benefits of using them on dementia sufferers in light of the risks. The federal Agency for Health Care Research and Quality recently reviewed existing research and noted the drugs can trigger strokes, induce body tremors, fuel weight gain and affect an elderly person's gait, increasing their chances of falling.

Federal and state regulatory authorities have begun scrutinizing the widespread use of atypical antipsychotics in nursing homes, through intensifying inspections of appropriate medication usage and readily citing nursing homes that overmedicate residents. The Centers for Medicare & Medicaid Services (CMS) recently "initiated a more rigorous process to oversee appropriate use of medicine," resulting in a 50 percent increase in the number of nursing home inspections that produced drug violations in the past three years.

Bruce Pollock, president-elect of the American Association for Geriatric Psychiatry, told the Wall Street Journal that atypical antipsychotics are not effective treatments for dementia.

“We know the more staffing there is and the higher quality of care, the less antipsychotic usage,” Pollock said.

Note from the MGH Community News: So how can we help protect our patients and loved ones from misuse of antipsychotic medications? Encourage families to be educated and involved in their loved-one’s care. Encourage them to speak up and, if they can’t solve the problem on their own, to seek the help of the state nursing home ombudsman. Also, see the lead article on the Eden Alternative in this edition of the MGH Community News.

Every state has a long-term care ombudsman program. In MA see Long Term Care Ombudsman Program Telephone numbers from the Massachusetts Executive Office of Elder Affairs: http://www.mass.gov/?pageID=elderssubtopic&L=3&L0=Home&L1=Service+Organizations+and+Advocates&L2=Long+Term+Care+Ombudsman&sid=Eelders For other states see the National Long Term Care Ombudsman Resource Center at: http://ltcombudsman.org/.

-Adapted from “Nursing Homes Overprescribing Antipsychotics” in MEDICARE WATCH, a biweekly electronic newsletter of the Medicare Rights Center Vol. 10, No. 25: December 11, 2007 and “Prescription Abuse Seen In U.S. Nursing Homes: Powerful Antipsychotics Used to Subdue Elderly; Huge Medicaid Expense” By Lucette Lagnado, the Wall Street Journal, December 4, 2007; Page A1.

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