Articles Posted in Dementia in Nursing Homes

Antipsychotic medications treat serious psychiatric conditions like schizophrenia and bipolar disorder. That was their original intention, anyway. In some nursing homes and hospitals, antipsychotics have found a new use in patients suffering from dementia. In an effort to keep difficult dementia patients calm, some nursing homes use these medications as a “chemical restraint.” For dementia patients who also suffer from schizophrenia or other psychiatric conditions, this can be an effective treatment. For other dementia patients, though, it can worsen the effects of dementia and cause severe side effects, including an increased risk of death. The Centers for Medicare and Medicaid Services (CMS), after months of preparation, last month announced a partnership with state health agencies, nursing homes, and health care advocacy groups to push for the reduction or elimination of antipsychotics as a treatment for dementia sufferers.

We have followed the effort to reduce use of antipsychotics for some time at the Maryland Nursing Home Lawyer Blog. The group of drugs known as “antipsychotics” includes “atypical antipsychotics” like Abilify, Seroquel, and Zyprexa; and older “typical antipsychotics” like Haldol and Thorazine. Concern over the issue goes back at least as far as 2005, when the U.S. Food and Drug Administration (FDA) issued a warning to doctors about risks from antipsychotic medications to dementia patients, including an elevated risk of dying from pneumonia or heart attacks. A report from the Department of Health and Human Services (HHS) released in 2011 found that up to one in seven nursing home residents received an “atypical” antipsychotic in 2007, and that almost ninety percent of the antipsychotic prescriptions issued to nursing homes that year were for dementia patients. CMS first announced its new initiative during a webcast on March 29, 2012, and it followed up with a formal launch on May 30.

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The Alzheimer’s Association, an organization established to promote both care for Alzheimer’s patients and research into eradicating the disease, recently published a report outlining the prevalence and cost of the disease in Maryland and the rest of the country. In addition to its conclusion that the cost of caring for Alzheimer’s patients will increase greatly over the next twenty to thirty years, the study found that a significant percentage of Alzheimer’s sufferers live alone, with no one to provide care even on a part-time basis. Alzheimer’s already constitutes a very large portion of nursing home and extended care costs. The increased incidence of Alzheimer’s and the lack of support for many sufferers cause concern for us as advocates for nursing home residents suffering abuse and neglect.

Alzheimer’s disease is the most common form of dementia, causing progressive degeneration of brain functions. It most often afflicts people over the age of 60. Little is known about the disease’s precise cause and means of progression, and there is no cure. The disease often manifests first with confusion or irritability, and can progress to forgetfulness and difficulty with language. People with the disease often suffer serious long-term memory loss, and eventually even bodily functions are affected, leading to death.

According to the Alzheimer’s Association, 5.4 million Americans currently suffer from the disease, 5.2 million of them over the age of 65. Almost thirty percent of Alzheimer’s sufferers receive Medicare or Medicaid. Seventy-five percent of people with Alzheimer’s will go to a nursing home by age 80, the Alzheimer’s Association estimates.This is compared to four percent of the general population, meaning that the costs will strain states’ Medicaid budgets.

The report found that about 15.2 million people provide non-professional care to Alzheimer’s sufferers nationwide, including 278,490 in Maryland. This mostly consists of family members and friends providing unpaid care. The report estimates the nationwide economic value of this unpaid care at $210 billion in 2011. Maryland’s share of that amount exceeds $3.8 billion. The caregivers themselves also tend to incur additional health care costs due to the stress of caring for an Alzheimer’s patient. This costs Maryland caregivers around $173 million each year.

Approximately 800,000 Alzheimer’s patients live alone, according to the study, and about half of them have no “identifiable caregiver.” These individuals face serious risks of illness and death due to their progressive inability to care for themselves. This affects not only their health but public health, as state resources must go towards caring for them, which could mean less funds from Medicaid and other programs for nursing homes. It could also mean influxes of residents into nursing homes, putting strain on administrators and staff.

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The Centers for Medicare and Medicaid Services (CMS), the federal agency that administers Medicare and Medicaid , has launched an initiative to promote reducing the use of antipsychotic medication in nursing home patients. The goal of the initiative is to spotlight the misuse of these medications in nursing homes, improve their monitoring and regulation, and promote non-drug treatments for certain conditions in nursing home residents. Nursing home staff often use antipsychotics to treat dementia symptoms, which may include agitation and aggressive behavior. Use of antipsychotic medications in dementia patients can have serious side effects, however, increasing their risk of complication and even death. The CMA’s initiative is the latest in a series of government efforts to curb antipsychotic use.

The CMS formally launched its initiative on Thursday, March 29 with a one-hour webcast entitled “Initiative to Improve Behavioral Health and Reduce the Use of Antipsychotic Medications in Nursing Homes [sic] Residents.” It describes the initiative as a “multidimensional approach” that incorporates research, public outreach, regulation, and training.

This Maryland Nursing Home Lawyer Blog has previously reported on the issue of misuse of antipsychotic drugs in dementia patients. The primary purpose of these drugs is the treatment of schizophrenia and bipolar disorder. Nursing home staff sometimes use these drugs with dementia patients, which is fine for the minority of dementia sufferers who also demonstrate symptoms of schizophrenia or psychotic behavior. Antipsychotic medications may only worsen the isolation and communication problems for the remainder of the nursing home residents with dementia.

A report released by the U.S. Department of Health and Human Services (HHS) in 2011, based on an audit conducted in 2007, found that nursing homes often use antipsychotic medications in ways that are neither approved for Medicare coverage nor approved by the Food and Drug Administration (FDA). According to the study, eighty-eight percent of the antipsychotic prescriptions issued that year were for nursing home residents with dementia. Overall, as many as 1 in 7 nursing home residents received an “atypical” antipsychotic drug. The Inspector General for HHS wrote that such uses “violate government standards for unnecessary drug use.”
HHS additionally found that some pharmaceutical companies have specifically marketed certain drugs to nursing homes. In 2009, the nation’s largest pharmacy dealing with nursing homes, Omnicare, agreed to pay $98 billion to the federal government and multiple state governments to settle allegations of receiving illegal kickbacks from drug manufacturers. A lawsuit filed by the U.S. Department of Justice in early 2010 against Pharmaceutical company Johnson & Johnson accused the company of paying kickbacks to pharmacies, including Omnicare, to both purchase and promote its products to nursing homes. This included the antipsychotic drug Risperdal.

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Antipsychotic medications are typically used to treat patients with schizophrenia or bipolar disorder, helping reduce and control delusional thinking and hallucinations. In nursing homes around the United States, staff also use antipsychotics for patients suffering from dementia as a way of controlling paranoia and aggression. These medications can be useful for the small percentage of dementia patients who actually demonstrate psychotic behavior and constitute a risk to other nursing home residents and themselves. For most dementia patients, antipsychotics may only further isolate them and make them even less communicative. This is of particular concern to families and loved ones of dementia patients, who wish to ensure that they are receiving the best possible care.

An FDA warning from 2005 gives notice to doctors of an increased risk of death from pneumonia or heart attacks among dementia patients prescribed atypical antipsychotics. This class of drug includes Abilify, Geodon, Invega, Risperdal, Seroquel, and Zyprexa. The agency added the older class of drugs known as typical antipsychotics to that warning in 2008. Typical antipsychotics include drugs like Thorazine and Haldol. Despite the warnings, off-label use of antipsychotic medications in dementia patients continues.

The Associated Press reports that nursing homes are beginning to take notice of the risks inherent in using antipsychotics for dementia and are gradually decreasing their rate of use. One nursing home in Florida has seen a reduction in the rate from twenty-five percent of all patients to a current rate of fourteen percent. A Brooklyn, New York nursing home went from thirty to fifteen percent without much trouble. Most patients taken off the antipsychotic regimen reportedly displayed significant improvements in both mood and behavior.

Among nursing home staff, the concern is that, without the antipsychotic medications, they will be unable to control aggressive or violent dementia patients. Some patients may truly need such medication, especially since there are no FDA-approved drugs specifically treating behavioral aspects of dementia. Patient advocates cited by the Associated Press argue that the use of such medications has more to do with keeping patients sedated for staff convenience. In situations where use of antipsychotics may be endangering a patient’s life, all other concerns should be secondary to protecting the patient.

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