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Can nursing homes get 300,000 dementia patients off deadly antipsychotics?

Original source:

Aljazeera America
David Martin
October 5, 2015

EL MONTE, Calif. — Even though Maria Guerrero and her husband childproofed their doors, her mother, Mary Sanchez, sometimes found a way to wander out of the house.

A neighbor called one night to report her walking in the middle of the street at 3 a.m.

“I said, ‘I can’t take the chance my mom will wind up walking out on the street and getting hit by a car,’” Guerrero recalled.

She looked for a secure nursing home specializing in dementia care and found what she thought was the perfect place: Idle Acre Convalescent, a 59-bed facility behind a wrought-iron fence on a quiet street east of Los Angeles. The facility has Medicare’s highest rating, five stars.

But behind the locked gate, more than half of Idle Acre residents receive antipsychotics, despite an FDA black box warning that these powerful drugs can cause death in people with dementia. Mary Sanchez was one of them, receiving the antipsychotic Risperdal.

In February, Medicare began considering antipsychotic prevalence in its rating system as a way to push nursing homes to limit their use. On the Centers for Medicare and Medicaid Services website, the federal agency said, “CMS is adding the antipsychotics usage to the star ratings as part of its commitment to reduce inappropriate use of these medicines … It is important that our quality measures and star ratings reflect these expectations.”

Despite Medicare’s new scoring system, America Tonight has found, more than 40 nursing homes, like Idle Acre, with five-star ratings that use antipsychotics at more than twice the national average. At Idle Acre, 52 percent of residents received antipsychotics from July 2014 through March 2015, according to Medicare’s Nursing Home Compare website

‘Enforcement lite’

The FDA has approved antipsychotics for use in schizophrenia and bipolar disorder, but advocates for the elderly say antipsychotics are often used off label as chemical restraints, sedating residents who are agitated or aggressive.

A Government Accountability Office report this year found one-third of nursing home residents with dementia receive antipsychotics. The national average for all nursing home residents is 18 percent.

Tony Chicotel, a staff attorney for California Advocates for Nursing Home Reform, said antipsychotic use accounts for a very small part of the overall formula determining how many stars a nursing home receives.

“The five-star rating system is sort of enforcement lite,” he said. “It’s not telling facilities, ‘If your rate is high, you’ve done something wrong. If you’re drugging people without the necessary clinical indications, you’ve done something wrong, and you’re going to have to pay for it.’”

Chicotel said too many nursing homes continue to see antipsychotics as a quick solution for residents’ difficult behavior. “It’s easy to call the physician and get a prescription and give it to them and suddenly they’re quiet,” he said.

Guerrero said she didn’t realize at the time her mother was receiving the antipsychotic Risperdal, which is approved for use in adults with schizophrenia. She noticed her mother would often look as she were in “a trance,” she said, and sometimes fall asleep in the middle of visits.

“I would ask the nurses, ‘Why is she so sleepy? They said, ‘Oh, she probably was up pretty late last night.’”

Neither Idle Acre, nor the nursing home’s owners, Sabu Enterprises, returned repeated phone calls from America Tonight.

Doctors’ training needs

Dr. Helen Kales, the founder and director of the University of Michigan’s Program for Positive Aging, examined data on more than 90,000 patients at Veterans Affairs hospitals. She found that antipsychotics are much more dangerous than previously believed in people with dementia.

Looking at the effect over a six-month period, she found the antipsychotic Haldol caused an additional death for every 26 patients with dementia receiving the drug. For Risperdal, the rate was one additional death for every 27 patients; Zyprexa, one additional death per 40 patients; and Seroquel, one per 50.

‘It’s easy to call the physician and get a prescription and give it to them and suddenly they’re quiet.’ Tony Chicotel California Advocates for Nursing Home Reform

Kales and her collaborators also found that risk went up with higher doses. Patients receiving several antipsychotics at once face the highest risk.

“We see this antipsychotic use not because doctors are bad or greedy or because they're trying to do the wrong thing but because they’re faced with such difficult problems clinically and that is the behavioral symptoms of dementia,” Kales said.

She added, “I guess the phrase is, If all you have is a hammer, everything looks like a nail. Out in the field we have, most providers are actually not psychiatrists. Most people that see people with dementia are primary care physicians, and they’ve probably received a little bit of training on these psychiatric medications in their training, but they haven’t received the kind of training that we think is necessary.”

Kales and her colleagues have created techniques to help caregivers find nondrug solutions to the agitation and other vexing behaviors associated with dementia. The key to the approach, she said, is finding the underlying cause, because patients with dementia are often unable to articulate the source of their agitation or discomfort.

A long way to go

In 2012, Medicare launched an initiative to get nursing homes to cut back on their use of antipsychotics. Since then, about 100,000 fewer nursing home residents receive the drugs.

“That’s amazing, at one level," Chicotel said. “On the other hand, if you’re looking at this issue as something that’s intolerable — one person on antipsychotics who doesn’t need it should not be tolerated — then we have a long way to go.”

He added, “You still have approximately 300,000 nursing home residents on antipsychotics, and that’s a number that’s embarrassing. That’s a national embarrassment.”

As for Sanchez, she left Idle Acre in an ambulance, dehydrated and malnourished and suffering from pneumonia and a serious infection, said Guerrero.

She was taken to a different nursing home that did not prescribe antipsychotics, Guerrero said. While there, Guerrero saw glimpses of her mother’s vibrant personality — even though she could no longer speak.

“There was no verbal communication,” Guerrero said. “She communicated everything with her eyes, and I really feel like I had that opportunity because she passed to have that quiet relationship with her.”