July 15, 2014

The Scourge of Antipsychotics in Nursing Homes

Every day I wake up in my house, I count my lucky stars I’m still living here. Five years ago, when I first got my Parkinson’s disease diagnosis, I started planning to sell my house and move into a senior living facility. I suspected I’d experience a rapid decline, and that I’d need lots of help… and soon.

So I visited one particular place downtown I’d heard some good things about. It’s close to our excellent Metro system, to the Kennedy Center, fine restaurants, and the museums and theaters that make Washington such a great place to live. As I walked around, the residents there seemed pleasant, interesting, and active. The apartments I saw looked nice. I even thought, “OK, I could live here.”

Oh boy.

The past five years in my own home -- where I’ve lived for about half a century – have been wonderful. Mostly, I’ve enjoyed a long and fortunate Parkinson’s “honeymoon,” during which my symptoms have been manageable. I’ve enjoyed my garden like never before. And easing into a “new” life with Parkinson’s has been immeasurably more comfortable, more fun, and less worrisome for me because of my two young Nepali housemates. The peace of mind I feel because they live here is priceless. 

Life is good.

Over the past weeks, I’ve seen more and more evidence that, for seniors, staying in one’s own home  – as long as you’re safe, comfortable, and happy there – is an excellent predictor of continuing wellness.

For a while, I’ve thought of posting a few thoughts about the positive impact of staying in one’s home. Then a friend mailed me a copy of the July-August 2014 issue of the AARP Bulletin. One particular story caught my eye: “Prescription for Abuse: Antipsychotics in Nursing Homes.” When I finished the article, I breathed another sigh of relief – and gratitude – that I’ve eluded that grim nursing home fate. Who knows what the future holds, but I hope I’ll never have to see the inside of such a place.

Here are a few of the bullet points from that scary article.

It’s a Big Problem
Estimates suggest that 20 percent of patients in America’s 15,500 nursing homes are given unnecessary antipsychotic drugs, mostly to make those patients more easy for staff to control. Said Todd Edelman, attorney at Center for Medicare Advocacy here in DC, "The misuse of antipsychotic drugs as chemical restraints is one of the most common and long-standing, but preventable, practices causing serious harm to nursing home residents today."

The reasons for this abuse are various, and often work in combination. Two big problems are inadequate personnel training and chronic understaffing.

Aggressive, Persuasive, Improper Marketing by Big Pharma
Antipsychotic drugs are designed to treat people with severe mental health problems, like schizophrenia or bipolar disorder… NOT seniors in nursing homes because they complain too much or need too much attention.

These potent drugs carry the FDA’s black-box warning that they are not intended for frail, elderly people -- or people with Alzheimer’s or other dementias. For these people, powerful antipsychotics can cause agitation, anxiety, confusion, disorientation, even death. The California Advocates for Nursing Home Reform issued this statement about those drugs: “They can dull a patient’s memory, sap their personalities, and crush their spirits.”

The government is catching on and getting tougher. In 2009, Eli Lilly paid $1.4 billion for marketing their antipsychotic Zyprexa to nursing home and senior living residents, when the company knew their drug had not received FDA approval as safe and effective for this elderly population.

At the time of that settlement, special agent Patrick Boyle – head of the Office of Inspector General for the U.S. Department of Health and Human  Services – said: “This case should serve as still another warning to all those who break the law in order to improve their profits.”

Another Black Eye for Greedy Big Pharma
In November, 2013 – just over half a year ago – Johnson & Johnson and its subsidiaries paid fines of $2.2 billion for aggressively marketing inappropriate drugs – including antipsychotics – to nursing homes.

That case also alleged kickbacks from Johnson & Johnson to doctors and to Omnicare -- the country’s largest long-term-care pharmacy provider -- for recommending its drugs, including the antipsychotic Risperdal (risperidone), to nursing home residents. The U.S. Department of Justice called that case “one of the largest health care fraud cases in history.”

“Informed Consent” Often Not Happening
Nursing homes are required by law to secure informed consent from patients – or designated family members – before powerful drugs like antipsychotics are administered. But that legal requirement is typically overlooked. Why? There are many possible explanations, probably (again) occurring in combination:
  • Uninvolved family members
  • Inadequate training
  • Exhausted, overworked nursing home assistants (NSAs)
  • High turnover rate for NSAs
Additionally, nursing homes are often woefully understaffed. Residents require lots of care. Many are incontinent. One estimate suggests that 60-70 percent of all nursing home residents have some type of dementia. In most of these places, the patient-to-NCA ratio should be about 5 to 1. In fact, the ratio is often higher than 15 to 1.

Tony Chicotel, staff attorney with the California Advocates for Nursing Home Reform, cites another issue that exacerbates the problem: “These facilities are highly medicalized, but doctors are rarely there.”

Steps Toward Improvements
The U.S. Centers for Medicare and Medicaid Services (CMS) – which oversees nursing homes that receive federal  money – has been working to improve the situation. Over a recent two-year period, the CMS reduced inappropriate use of antipsychotic drugs in its nursing homes by 15 percent. Over the next few years, the CMS hopes to reduce unnecessary medication by 30 percent.

Many facilities are simply trying to address the problems they already know exist, like inadequate staffing and training. Others – like the Beatitudes facility in Phoenix – are changing the way they care for their patients with dementia based on Tom Kitwood’s book Dementia Care Reconsidered: The Person Comes First

Here’s one example of the adjustments they’ve made there: Because people with dementia typically have irregular, disturbed sleep/wake cycles, the staff at Beatitudes lets these residents sleep and eat whenever they want. Patients can do what they want to do whenever they like. Though the prescription may sound like an additional staff burden, managers there report that most patients no longer resist care, and that the facility runs more smoothly because they have positioned patients’ wishes first.

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The issue of nursing home drug abuses – especially with antipsychotics – is just one reason why staying in one’s own home is good for seniors’ health. In the days ahead, I’ll share others.


Anonymous said...

For the first time I developed major depression after several surgeries. I decided to retire at age 65 from a very demanding job with a heavy traffic commute, sold my home and purchased a nice condo. I am unable to tolerate antidepressant meds due to hypotension, and other concomittant medical issues. There is a very strong family history of depression bipolar d/o and suicide over several generations, including my sister, 2 brothers, and a daughter with depression and another with bipolar d/o. Three yrs after onset of my depression it is getting worse. I sleep almost all the time and enjoy nothing. I am unable to socialize b/c of the symptoms. I am extremely anxious. After consultation with multiple psychiatrists @ major a University
hospital they are recommending ECT. I am 68 yo and it frightens me as I live alone and had hoped to continue to do so. B/C I worked in the healthcare field I am quite aware of the adverse effects and the fact that response to ECT can vary greatly. I prefer death to institutionalized living at my age, as there is little to no quality of life in such a setting, especially if you are not quite wealthy. I have planned financially for my retirement and would have been fine had this depression not occurred. I do not believe I can afford to have someone come live-in. One never knows what hand you may be dealt in life.I completely agree about the pharma companies as I have seen it throughout my career in many instances for many different conditions. It is difficult to trust the health care system since this development.

John Schappi said...

I wish I had something helpful to suggest! I'll be talking more later this week on depression and suicide, prompted by the Robin Williams news.