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Use of chemical restraints in nursing homes called an epidemic

Ventura County Star
Tom Kisken
March 24, 2011

Nearly 25 percent of the residents in California's nursing homes are placed on antipsychotic drugs, often used as sort of a chemical leash to control behavior in a trend a watchdog called an epidemic Thursday at a symposium.

The drugs can double the risk of death for seniors with dementia and cause side effects ranging from stroke to delirium, according to speakers at an Oxnard conference called "Toxic Medicine." Often the drugs are given in nursing homes or other facilities for dementia without the informed consent of residents or surrogates and are used as a restraint rather than to treat psychiatric conditions.

Over the past decade the use of the drugs has evolved from a sniffle to a flu to something much worse, said Sylvia Taylor Stein, of the Long Term Care Services of Ventura County ombudsman program.

"By 2010 we had an epidemic," she said in a symposium organized by her group and the California Advocates for Nursing Home Reform. It was attended by a packed house of nursing home leaders, assisted-living administrators, elder abuse lawyers and state licensing agencies.

Some at the conference linked the use of antipsychotics to staff shortages that make it impossible for employees to properly care for patients, state cuts in mental health programs that have brought more patients with psychiatric problems to long-term care facilities and doctors who have a drug-first mentality when it comes to long-term care residents.

Anthony Chicotel, an attorney with the California Advocates for Nursing Home Reform, said there are appropriate uses of the medication, such as when a patient has illnesses like schizophrenia. But Medicare statistics from the second quarter of last year showed 24.2 percent of the residents in the state's nursing homes were on antipsychotics. Medicare statistics from 2009 showed the use of the medication fluctuated greatly at different Ventura County nursing homes Ñ from a low of 7 percent of the patients on the drugs seven days over one week to a high of about 30.6 percent.

Often, use of the drugs becomes ingrained in a long-term care site's culture, Chicotel said. When patients with dementia or other issues yell in the middle night, hit other residents or try to flee the place, staff members call the physician.

"Hey doc, we have a new resident. He's out of control. He's throwing feces. We need a pill," he said.

Dave Merkley is administrator at the Glenwood Care Center, an Oxnard nursing home where data showed about 17 percent of the residents were on antipsychotic drugs at the end of 2009 Ñ better than the state's average. The facility already works to make sure that drugs are used only in appropriate situations, but Merkley said he planned to talk with the facility's medical staff to make sure other options are being considered.

"We rely on our doctors," he said. "We explain what the situation is and the doctors do the diagnosis."

Dr. Robert Buckingham, an Ojai internist involved in long-term care, challenged the claim that doctors prescribe antipsychotics more than they once did.

"I would say if anything they're used less today than they were 10 years ago," he said.

In cases where a patient with dementia is at risk of hurting himself or someone else, the medication may be unavoidable, he said. Once the patient is stabilized, the drugs should be withdrawn.

"The long-term use of antipsychotics is the last recourse," he said.

But lawyers involved in elder abuse cases said over-reliance on the drugs is common.

"I don't think the question is who to blame, it's what to do," said Jody Moore, an attorney in Thousand Oaks.

Laws are in place to protect patients, including a prohibition on using medication for the purpose of discipline or convenience, Chicotel said. But enforcement is weak and the drugs are routinely prescribed without obtaining informed consent.

Doctors are responsible for getting consent but nursing homes are culpable for verifying it, he said, adding that not obtaining consent is battery.

At least one assisted living facility administrator at the symposium vowed to challenge doctors on whether they've really obtained informed consent. Chicotel and others said change will come through the efforts of not only nursing home and doctors but law enforcement, regulators and watchdogs.

Advocates cited the drastic decline in the use of physical restraints in nursing homes over the past two decades, suggesting a similar drive is needed for antipsychotics.

"The idea is we're not taking it anymore," Chicotel said.