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Finding alternatives to potent sedatives
The Boston Globe
Second of two parts
LITTLETON - Marjorie Bontempo was a changed woman after moving into Life Care Center of Nashoba Valley, a Littleton nursing home where the staff doesn’t believe in using antipsychotic drugs simply to calm residents.
A physician had prescribed an antipsychotic for Bontempo a year earlier, after Alzheimer’s disease had transformed her from an accomplished seamstress and demure family peacekeeper into a cantankerous, confused woman who refused to eat. The medicine eased her aggression but left her dazed, said her daughter, Patty Sinnett.
Nashoba’s nurses took Bontempo off the powerful sedative. Sinnett went to visit soon after and found her mother in the activity room watching a Clark Gable movie.
“She started explaining the whole movie to me, like a normal person would,’’ Sinnett said. “It was the first time I had had a conversation with her in a year. It was incredible.’’ The Littleton facility is one of a small but growing number of nursing homes that are treating the agitation and disruptive behavior that often accompany dementia without resorting to antipsychotics.
Instead, Life Care Center and similar homes try to tailor care to each resident, to make it familiar and comforting. Staffers comb residents’ pasts to learn their preferences, hobbies, and accomplishments, tapping bedrock emotions that endure long after memory fades.
The Globe reported Sunday that many homes still rely heavily on antipsychotics to deal with aggressive residents, though most of these residents do not have conditions that nursing home regulators say warrant use of the drugs. And federal authorities have warned of sometimes lethal side effects when antipsychotics are taken by elderly dementia patients.
Industry leaders say that the drugs must be used at times to protect residents and staff, and that many of the nondrug approaches being tried require specialized training that far too few nursing home workers have received, and often more staffing.
They note that drug regulators have not approved any medications specifically to manage the difficult behaviors exhibited by residents with dementia, and that physicians are allowed to prescribe antipsychotics “off-label’’ for conditions other than what they were designed for: serious mental illnesses such as schizophrenia.
Overall use of the drugs in nursing home patients without mental illnesses has declined since 2005, according to the Globe’s analysis of federal data. The numbers show that Nashoba drove down its use of antipsychotics from six years ago, when nearly a quarter of residents without illnesses warranting antipsychotic use received them anyway. In 2010, that number was zero.
The linchpin was a new director of nursing, Nancy LaRock, who scoured each patient’s files and discovered that roughly 30 of the home’s 120 residents were on antipsychotics. Easily half of them didn’t have a condition that would warrant the medications.
LaRock, who had a background in psychiatric care, started weaning residents off the medications and training staff about alternative strategies.
“One of the biggest challenges was from families,’’ she said. “I got some push-back from families who wanted mom to have this drug because she was so much easier to be with,’’ LaRock said. “As far as I’m concerned, the antipsychotic masks who that person really is.’’
From the circular layout of its Alzheimer’s unit - so residents don’t encounter a dead-end in a hallway, a potential source of stress for those who wander - to the goats and llamas grazing in its pastoral front yard, Nashoba stands out.
Executive director Ellen Levinson, whose two golden retrievers often greet visitors at the front door, said she has found that animals have a calming effect. The walls of the 27-bed Alzheimer’s unit are lined with animal pictures, and bird feeders hang from nearly every window.
A caretaker sometimes leads the llamas through the halls and into the Alzheimer’s unit, where even residents who relentlessly wander stop to pet the regal creatures.
Activities and care are matched to residents’ individual personalities and abilities.
For 88-year-old Richard Pinkham, a former electrician, staffers assembled a “tool box’’ full of paint brushes, measuring tapes, and other gadgets so he can still dabble.
They found that Bontempo, who wasn’t eating when she first arrived in 2010, loves hot chocolate - any time of day, any time of year. Now they bring her a cup at the start of every meal, which jump-starts her appetite. And she is rarely aggressive.
“Margie really enjoyed dancing, so we try to talk to her about that,’’ said Erica Labb, program director of Nashoba’s dementia care unit. “It is often trial and error and we just keep trying new things until we find the right combo.’’
Many of the residents are no longer able to speak, so their behaviors - tears, screams, slapping, smiles - are how they communicate.
“If someone is combative during a shower, it may be that she is afraid, so we may start with just her feet,’’ Labb said.
Staffers ask family members detailed questions about a resident’s personality before Alzheimer’s set in: the time of day they preferred bathing, favorite foods, hobbies, cherished accomplishments.
Caring for people with dementia, without relying on antipsychotics, requires nursing home staffers to become detectives, said Paul Raia, vice president of clinical services for the Alzheimer’s Association of Massachusetts and New Hampshire.
Raia, who trains nursing home staffers in dementia care, encourages them to methodically chart difficult behaviors to pinpoint possible triggers. In one recent case, a male resident was inexplicably hitting others, but by tracking his actions, the nurses discovered that he struck only during the day, and only when he was in a certain section of a room.
“We learned the light hurt his eyes,’’ Raia said. “It was in a day room and all we had to do was draw the shades so the light wasn’t in his eyes, and it didn’t happen again.’’
Dr. Jonathan Evans, a medical director at two Virginia nursing homes, said he prescribed antipsychotics for years for dementia patients, often feeling pressure from overwhelmed staffers or agonized families who believed the medications would help their loved ones.
“We are trained as physicians to think that every problem has a potential solution, and the most widely used solution is a medication, but that doesn’t work for every problem,’’ said Evans, president-elect of the American Medical Directors Association, a national trade group for physicians who work in nursing homes.
Evans stopped prescribing antipsychotics for dementia patients after the government warnings of lethal side effects, and he said he will dedicate his presidency to educating other caregivers that challenging behaviors from dementia may be due to untreated pain from arthritis or an infection, or fear.
He has found that people with dementia often understand and respond better to nonverbal communication - a gentle approach at eye-level - than to words.
“These behaviors are often a primitive, biological response that is like a reflex,’’ said Evans, who also is a consultant to Life Care Centers of America, which operates more than 200 facilities in 28 states, including Nashoba.
Across the country, a variety of approaches have been developed to help nursing home staff better understand and manage difficult behaviors without using antipsychotics, but researchers are still trying to determine which methods work best.
Such drug-free approaches can be labor-intensive.
The Globe’s analysis found a link between staffing levels in nursing homes and the use of antipsychotics. Those with the highest percentage of residents who receive antipsychotics contrary to nursing home regulators’ recommendations also tend to have the lowest numbers of registered nurses and nurses aides.
These homes also typically have more residents on Medicaid, a government insurance program that reimburses nursing homes at a far lower rate for patient care than private insurers do, so the homes would have less money to hire staff.
Half of the residents in Nashoba’s Alzheimer’s unit have private insurance, which means the facility is receiving $412 daily for each of these residents, compared with the $184 daily rate for the other patients, whose care is covered by Medicaid, according to Levinson, the executive director.
That allows Nashoba the luxury of higher staffing levels than the state median, according to the Globe’s analysis.
“Money helps with staffing,’’ said Levinson, the executive director, “but having the right philosophy is not expensive.’’
Nashoba does not accept residents who have a history of combative behaviors that could hurt other residents. That typically means that large, strong, aggressive men who are still able to walk are not allowed.
But even homes that take difficult dementia patients, such as Beatitudes Campus in Phoenix, have been able to reduce their reliance on antipsychotics. The percentage of residents placed on the drugs for illnesses that do not warrant the medications dropped from 31 percent in 2005 to 19 percent in 2010, according to federal data.
Tena Alonzo, Beatitudes’ director of research and dementia programs, said the facility’s focus has not been on reducing the use of antipsychotics, but on making each resident as comfortable as possible. Baths, meals, and activities are structured around residents’ preferences instead of staff schedules. In the process, antipsychotic use has steadily dropped.
“If someone is comfortable, everything is easier and staff doesn’t turn over,’’ Alonzo said.
Federal data show that Beatitudes has about 50 percent more registered nursing time per patient than the national median, but Alonzo said the focus on comfort care has allowed it to substantially cut costs in other areas.
In a study that has not yet been published, Beatitudes found that it slashed its spending on briefs because staff regularly helped incontinent residents to the bathroom. Alonzo said spending on dietary supplements also dropped dramatically because residents with dementia, who often lose their appetites, were more interested in eating when given morsels of chocolate or other favorite comfort foods.
“Chocolate is able to get through that cloud of dementia,’’ Alonzo said. “I can’t change the way you think with dementia, but I can change the way you feel.’’