SNF’s Use of Antipsychotics for Dementia
Nearly 2,500 nursing home residents in Massachusetts were given powerful antipsychotic drugs last year that were not intended or recommended for their medical condition, a practice that is more common here than in most other states, according to a Boston Globe analysis of federal data.
Data collected by the federal Centers for Medicare and Medicaid Services show that 28 percent of Massachusetts nursing home residents were given antipsychotics in 2009. Of that group, 22 percent - or 2,483 - did not have a medical condition that calls for such treatment. That rate was the 12th highest in the nation, according to the federal data.
The use of such drugs is especially worrisome in nursing homes because a substantial number of residents suffer from dementia, a condition that puts them at greater risk of death when given antipsychotic medications. Twice in the past five years, federal regulators have issued nationwide alerts about troubling and sometimes fatal side effects when antipsychotics are taken by people with dementia, including increased confusion, sedation, and weight gain.
“Way too many patients in nursing homes are treated with antipsychotics purely to sedate them or to control behaviors that are difficult for the staff,’’ said Robert A. Stern, an Alzheimer’s specialist and brain researcher at Boston University School of Medicine. “To the defense of nursing homes and nursing home staff,’’ Stern said, “they are indeed understaffed, they are indeed under-trained, and it takes an awful lot of well-trained people to manage the difficult behaviors that can be exhibited by people with dementia.’’
A recent Boston Globe editorial also noted an additional possible reason for the over-prescription of antipsychotics in these situations, pharmaceutical companies’ promoting the off-label use of drugs to increase their profits. “Off-label’’ use of a drug is legal as long as a drug company does not promote it. Attorney General Martha Coakley has joined a federal suit charging Johnson & Johnson with using kickbacks to boost nursing-home sales of Risperdal. Johnson & Johnson is accused not just of promoting Risperdal for patients without psychosis but of providing kickbacks to Omnicare, a middleman that supplied drugs to nursing homes and advised doctors what to prescribe. Last fall, Omnicare settled its part of the suit for $98 million. Attorney General Coakley is also promising to closely monitor antipsychotic use among the elderly.
Specialists say antipsychotics can improve the quality of life for some dementia patients who suffer from extreme agitation and sleeplessness, common symptoms of Alzheimer’s. But too often nursing homes don’t regularly reevaluate patients’ medications to determine whether the antipsychotics are, in fact, effective and whether the dose can be lowered or eliminated, said psychologist Paul Raia, vice president of clinical services for the Massachusetts and New Hampshire Alzheimer’s Association. Raia helps train nursing home staff in behavior management techniques that can ease agitation and the need for the drugs - skills and training that, specialists say, are often lacking in nursing homes in Massachusetts and across the country. In these homes, he said, as many as 80 percent of the residents are on antipsychotic drugs. “And then I walk into a good place, one with training, and see 2 or 3 percent on these medications,’’ he said.
A nursing home’s track record for antipsychotic use often is a good predictor for future patients, according to new research from the University of Massachusetts Medical School. The scientists analyzed data from 1,257 nursing homes nationwide and found that patients newly admitted to facilities with some of the highest rates for prescribing antipsychotics are 37 percent more likely to receive the drugs than patients entering homes with the lowest prescribing rates.
Alice Bonner, the state’s top nursing home regulator as director of the Bureau of Health Care Safety and Quality, said “culture change,’’ including a growing consumer movement that focuses on more closely involving families and patients in care decisions, can lower the use of psychotropic drugs. “We can do better, and use fewer drugs, and do more with behavioral interventions by changing the way we deliver care in nursing homes,’’ she said. Her agency is developing a brochure for nursing homes to give new residents and their families, encouraging them to ask about the medications prescribed.
For Sharlene Hemp, a North Andover resident who says her father died from side effects of psychotropic drugs just 34 days after entering a nursing home, the answer is legislation. Her father had Alzheimer’s, but she said the family was never told about the medications nor of the potential lethal side effects, until after his death in 2001. Hemp persuaded her state senator, Steven A. Baddour, to file legislation that would require all Massachusetts nursing homes and their prescribing physicians to obtain written permission from a patient’s health care proxy, which is often a family member, and a court appointed guardian before using antipsychotic medications. A public hearing was held on the bill in January, and it remains in committee. “When you put a loved one in a nursing home, you are putting your trust in the nursing home and the doctor,’’ Hemp said. “But you don’t know when they go in that they are given all these drugs, and especially dementia patients, because they can’t tell you what they are given.’’
-From “Nursing home drug use puts many at risk; Antipsychotics given to some with dementia” by Kay Lazar, The Boston Globe, March 8, 2010 http://www.boston.com/news/health/articles/2010/03/08/antipsychotic_drug_use_for_dementia_patients_is_questioned/ retrieved 3/8/10 and “ GLOBE EDITORIAL : All eyes on antipsychotics”, The Boston Globe, March 22, 2010, http://www.boston.com/bostonglobe/editorial_opinion/editorials/articles/2010/03/22/all_eyes_on_antipsychotics/ retrieved 3/22/10.
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