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Southwestern PA antipsychotic drug use raises concern

Original source:

Pittsburgh Business Times
Kris B. Mamula
July 13, 2012

Unwarranted treatment of elderly at issue

The use of antipsychotic medications on nursing home patients who do not have a related diagnosis is higher in southwestern Pennsylvania than the statewide and national medians — 18.9 percent locally compared to 15.65 percent statewide and 16.7 percent nationally, according to a Pittsburgh Business Times analysis of Medicare data.

Snyder Memorial Health Care Center in Forest County had the highest rate in the state at 74.3 percent and Latrobe Health and Rehabilitation Center had the third-highest at 54 percent.

“The shame, the terrible problem of physical and chemical restraints in the institutions for our elderly nationwide, is a disgrace,” said Morris Kaplan, operating partner at the 171-bed Gwynedd Square Center for Nursing & Convalescent Care in Lansdale, about 30 miles northwest of Philadelphia. “Pharmacological intervention is very often appropriate, but many nonpharmacological approaches exist. When they say there’s no data, they’re wrong.”

Medicare will begin disclosing antipsychotic medication usage inside nursing homes by the end of July as part of a government push to curb inappropriate use of the drugs among the elderly. It plans to do so as a new quality metric, thus increasing pressure on operators to find ways of reducing unwarranted use.

“It will make providers really pay attention to their numbers,” said Charlene Kish, vice president of skilled nursing and rehabilitation at Concordia Lutheran Ministries, a Cabot-based long-term care provider. “It’s a big deal.”

Latrobe Health Administrator Steve Hausman said the numbers weren’t a surprise because the facility admits patients from long-term psychiatric treatment centers.

Using a database developed by the Boston Globe based on Medicare reports for 2009 and 2010, the Business Times created a snapshot of antipsychotic medication use among Pennsylvania nursing home residents who don’t have a related diagnosis. Doctors may order medications for any purpose, a practice called off-label prescribing.

But antipsychotic medications pose special dangers to the elderly, including increasing the risk of death, according to studies. A Canadian study of more than 40,000 people, for example, found that nearly 14 percent of nursing-home residents on antipsychotics had a serious health event within a month of use, compared to 4 percent not taking the drugs.

“The literature is out there — a lot of people don’t have indications for these drugs,” said Dr. Susan Levy, medical director at Levindale Hebrew Geriatric Center and Hospital in Baltimore. “We have a lot of families who don’t want them stopped. It’s not easy.”

Geodon, Abilify, Risperdal, Seroquel and Zyprexa are among the antipsychotic drugs increasingly being used in nursing homes. They are FDA-approved treatments for schizophrenia, bipolar disorder and major depressive episodes. But government reports indicate use of these medications in nursing homes among people without a related diagnosis has been edging up over the past decade. Now, the Centers for Medicare and Medicaid Services wants to cut antipsychotic drug use by 15 percent by the end of the year, then ratchet it down further in future years.

“These drugs often don’t work well and they’re very dangerous,” said Alice Bonner, director of the division of nursing homes in the survey and certification group at the CMS, which operates the Medicare program. “We are using medications to address behaviors and symptoms in people with dementia at a very high rate now — at least one in four nursing home residents may be on an antipsychotic when diagnosed with dementia.”

Snyder Memorial had the highest rate of antipsychotic drug usage in Pennsylvania at 74.3 percent, the Business Times found. The facility is a regional center for Huntington’s disease, which causes mental problems, and antipsychotic medications are an approved treatment by the Food & Drug Administration.

However, at many other nursing homes, doctors prescribe the medications off-label to control unruly behaviors associated with dementia, a group of related symptoms that can distort thinking and memory in the elderly and affecting about 60 percent of all nursing home residents. Vincentian Home, a 120-bed facility in McCandless, for example, limited its use of the drugs through frequent record monitoring with a pharmacy consultant and focusing first on behavioral change.

Vincentian’s use of antipsychotic medications among residents without a relevant diagnosis was just 5 percent, according to the Medicare database, less than one-third the statewide average of 15.7 percent.

“We’re strong in staff education,” said Susan Lewandowski, VP of clinical services. “We redirect resident behavior before chemical or physical restraints.”

Consistent work assignments to foster familiarity with patients, activity programs and music therapy are other strategies used in lieu of drugs. At Gwynedd Square Center, where these strategies have been used for years, the rate of antipsychotic usage was just 7.8 percent, roughly half the statewide average, according to the Medicare database.

Doctors — not nursing homes — write prescriptions and state nursing home inspectors rarely challenge a physician’s judgment, said Dr. Arlene Seid, medical director of quality assurance at the state Department of Health. One danger of antipsychotic medications is masking an underlying problem, such as pain.

“We think it’s a bad idea because it takes away the ability of the elderly to think and act and behave in ways to get better,” she said. But finding the root cause of problem behavior takes staffing at a time when about 65 percent of nursing home residents are covered by Medicaid, which pays an average of only $8 an hour for care, according to the Pennsylvania Health Care Association. Medicaid covers low-income people without assets, and the low reimbursement means nursing homes with a high number of Medicaid patients are stretched thin.

Dr. David Nace, chief of medical affairs at University of Pittsburgh Medical Center Senior Communities, said few studies have addressed the effectiveness of nonmedical interventions for dementia-related behavior problems.

“There’s no good evidence that those things are highly effective,” he said. “Well-done randomized trials with controls are absent.”

Among residents at UPMC’s Canterbury Place in Lawrenceville, 32.2 percent of its 59 residents were on antipsychotic medications without a diagnosis of a psychotic problem, according to the Medicare database.

Dr. Roy Monsour, a psychiatrist on staff at Loyalhanna Care Center in Latrobe, also defended use of antipsychotics in some patients with dementia. At Loyalhanna, 28.1 percent of the 106 residents were on the drugs, but did not have a diagnosis of psychosis, according to the Medicare database, and the number of nurse minutes per resident per day was 18, less than half the statewide average of 42.2 minutes.

Loyalhanna also has a large Medicaid population — 67 percent, according to Medicare records.

“These are medications that, quite frankly, I would rather not use,” Monsour said. “They don’t work even 50 percent of the time, but they are the medications we’re left with. I have families begging me to do something. They trust you to do the right thing.”