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Overmedication in the Nursing Home

Original source:

New York Times
JANUARY 11, 2010
by Paula Span

The number jumped out at me as I was reading a newly published study on mental health treatment in nursing homes: 71 percent.

Within three months of admission, a team of University of South Florida researchers determined, 71 percent of Medicaid residents in Florida nursing homes were receiving a psychoactive medication - an antidepressant or anti-psychotic, say, or dementia drugs - even though most were not taking such drugs in the months before they moved in and didn't have psychiatric diagnoses. Fifteen percent of residents were taking four or more such medications. But only 12 percent were getting nondrug treatments like behavioral therapy.

Unlike me, Victor Molinari, a professor of aging at the University of South Florida and lead author of the study, wasn't startled by those statistics. "They confirmed what I suspected," he told me in an interview. "And people who work in nursing homes wouldn't be surprised."

To have a great majority of residents on these powerful drugs isn't, on the face of it, an indictment of the way they're cared for. Mental health problems are rampant in nursing homes and a primary reason elderly people move in; some observers have taken to comparing nursing homes to psych wards. So some proportion of residents should be receiving treatment, possibly including medication, for anxiety, depression, bipolar disease, schizophrenia or the behavior problems that stem from dementia.

But 71 percent?

"It seems the use of psychoactive medication is trumping the use of nondrug treatments," Dr. Molinari said.

And given the possible interactions with the many other drugs most residents take, an average 10 or more prescriptions, "it could well be that we're causing problems like falls, confusion and delirium, and hospitalizations," he cautioned.

This was not supposed to happen. Nursing homes' reliance on psychoactive drugs has troubled professionals in geriatrics for years, so a major reform passed by Congress, in the Omnibus Budget Reconciliation Act of 1987, required that new residents be assessed for mental illness and encouraged use of nonpharmacological treatments.

But there's a major loophole. In many states, residents being admitted directly from hospitals are exempt from screening. As a result, federal data show, fewer than half of residents with major mental illnesses receive the mandated assessment. "The spirit of O.B.R.A. has been violated," Dr. Molinari said.

Only half of nursing homes provide weekly patient consultations with psychiatrists, psychologists or other mental health experts; even fewer provide consultations with those who specialize in working with seniors.

In addition, staffs are stretched thin and inadequately trained in mental health care. With a pill a quicker and simpler intervention than the alternatives, probable overuse is the result.

"I suspect what happens is, at 3 a.m. Mrs. A. starts yelling in her bed. The aide tries to calm her down and can't, so the nurse calls the consulting physician and gets Mrs. A on a tranquilizer - and she stays on it, whether or not she needs it," Dr. Molinari said. If the aide had fewer patients to care for and more time to soothe one who was agitated, if she'd had better training in responding to behavioral problems, she might have been able to settle Mrs. A down without Librium.

(Some of these medications are being prescribed for off-label purposes, that is, for conditions that have not been approved specifically by the Food and Drug Administration. Last January, for instance, the Justice Department brought criminal charges against Eli Lilly, accusing the big pharmaceutical firm of illegally marketing its anti-psychotic Zyprexa to doctors who work in nursing homes and assisted living facilities, and encouraging them to prescribe it for sleep disorders and dementia. Its approved use is to treat schizophrenia and bipolar disorder [pdf]. Lilly agreed to pay $1.4 billion in a related civil settlement.)

Dr. Molinari declines to point fingers, though. "This is not a matter of unethical medical people pumping in medications and nursing homes cutting corners," he said. "It's a systemic problem." He thinks it requires a systemic solution, too, including more mental health professionals specializing in geriatrics and better training for the entire staff. Medicare parity, under which mental health care is reimbursed at the same rate as other illnesses, begins to phase in this year and may help.

While we're waiting for systemic solutions (and it could be a long wait), families with elders in nursing homes would do well to keep track of the drugs the seniors are taking and to monitor the effects.

"For years, I've had calls from family members saying, 'Mom was completely lucid when she went into the nursing home, and a week later she no longer recognized us,'" said Janet Wells, public policy director of NCCNHR, formerly the National Citizens' Coalition for Nursing Home Reform. "Families should question why drugs are prescribed, do some research. A lot of drugs are being used as restraints."

If a resident seems to hallucinate or show greater confusion after a shift in drug regimen, bring your observations to the director of nursing (not to the aides who provide the bulk of hands-on care but have little authority to make changes). You can also consult an outside physician or the local ombudsman for long-term care.

And take advantage of the federal requirement that nursing homes hold quarterly care planning conferences to assess each resident's needs. "Regularly attend team treatment meetings," Dr. Molinari said, "so you have a voice."

Paula Span is the author of the recently published "When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions."