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Nursing Homes Temper Their Reliance on Drugs

Original source:
Barbara Williams
July 14, 2013

Josephine Chalupa had the shower cap on — never a good sign. It meant she was on a tear, hating anyone and anything that crossed her path at the nursing home in Norwood where she lived.

She made a nasty comment about a visitor’s shoes and shouted when anyone sat next to her. She demanded someone pull a tooth that was giving her so much trouble. She pinned a supervisor against the wall with her walker so she could yell at him about how much she hated the food.

“There was a lot of rage,” said her daughter, Christin Chalupa. “She was always yelling and screaming, just hating life in general.”

Chalupa, 91, was suffering from serious side effects of a fistful of drugs, her daughter said, including an antipsychotic medication that nursing home patients are frequently given by overworked staff to make them docile.

Today, Chalupa is friendly and social. She participates in activities, chats with relatives and is polite to the staff, her daughter said. The dramatic change came when the nursing home weaned her off the medications and, rather than drugging her when she became agitated, found other ways to keep her calm.

Josephine Chalupa may well be the personification of a new trend in nursing home care — fewer drugs and more personalized attention.

Across the nation, nursing home patients like Chalupa are frequently being drugged with antipsychotics to make them easier to control. While the drugs caused Chalupa to become agitated, they generally make patients less demanding. Often, loved ones find them slumped in wheelchairs, unaware of their surroundings and barely able to speak.

“It’s a very prevalent problem — a form of chemical restraint,” said Robyn Grant, director of public policy at the National Consumer Voice for Quality Long-Term Care, a patient advocacy group. “These drugs turn people into zombies and families are saying their loved one doesn’t even recognize them.”

Nationwide, 25 percent of nursing home patients are on antipsychotics, according to a study by the federal Centers for Medicare & Medicaid Services. It is even more widespread in North Jersey, where facilities report up to 37 percent of their patients have been given the drugs. The Centers for Medicare & Medicaid Services has set a directive that facilities should reduce their use of the medications by 15 percent, but few homes have complied.

That’s because nursing home administrators say there is no easy fix. Weaning patients off drugs is complicated. And keeping them off requires facilities to completely rethink their programs and staffing at a time when many are facing cuts in federal and state funding.

“Treating these patients isn’t an exact science, and we may have to introduce new medications while discontinuing others — it’s difficult to find that balance,” said Matthew Russo, administrator of the Armenian Nursing Home and Rehabilitation Center in Emerson, where 23.9 percent of the patients were on the drugs in 2012.

Federal health officials say getting elderly patients off antipsychotic drugs is crucial because such medications pose a risk of serious complications when taken by those who aren’t suffering from a mental illness.

“The elderly can be affected with a higher incidence of stroke, cardiac and respiratory problems and even death,” said Dr. Diego Coira, chairman of the department of psychiatry and behavior medicine at Hackensack University Medical Center.

Research has shown that the risk of death doubles when these drugs are given to patients with dementia. The drugs can also render elderly patients who don’t need them immobile, leading to inadequate food and liquid intake, incontinence, infections and bedsores, experts said.

“These medications do have a place, Coira said, “but they are overused.”

Marketing of drugs

Pharmaceutical companies have encouraged the use of these medications in nursing homes, advocates said. In fact, 36 states filed suit against Johnson & Johnson contending the company improperly marketed the schizophrenia drug Risperdal for the treatment of Alzheimer’s disease and dementia. The company was also accused of providing lucrative agreements to physicians who prescribed the drug off-label.

J&J agreed last August to pay $181 million to resolve the claims. The company did not admit any wrongdoing in the case, said Teresa Mueller, a company spokeswoman, who declined to comment further.

One staff member with Buckingham at Norwood Care & Rehabilitation Center is all too familiar with the reasons some facilities turn to these medications. Colleen O’Keefe, assistant director of nursing at Buckingham, said patients would scream, spit on her and throw food across the room.

“We have a lot of residents with senile dementia with behavior disturbances. People that would hit you, fall a lot and didn’t want to eat,” O’Keefe said.

“I was old school — if you acted out, we fixed you with a pill,” she said.

But Buckingham has evolved as a leader in New Jersey in caring for the elderly, drastically reducing its use of antipsychotics. It has developed a personalized-care approach that centers on meeting each patient’s individual needs — for instance letting patients choose a shower or bath, and feeding themselves if they want, no matter how long it takes — rather than drugging them when they become frustrated and difficult.

“We went down from about 33 percent [of our patients given these drugs] to about 3 percent,” said Batsheva Katz, a vice president for Windsor Healthcare Communities, the parent company of Buckingham.

“This really isn’t a choice — this is the way we need to treat the elderly today,” she said. “Patients have a better quality of life.”

Buckingham, which started its personalized approach several years before federal officials addressed the problem, puts an emphasis on building a bond between caregivers and residents. Staffers learn a resident’s history, including longtime habits, career, hobbies and family members, as well as current needs. Permanent assignments, where the same caregivers tend to the same residents each day, have been instrumental in building trust, said Helene Ledany, an administrator at the home.

“We have a resident we’ll call ‘Bill’ who was a photographer, had done a lot of walking in his life and never got up before 10 or 11 a.m.,” she said. He was difficult to deal with when awakened at 7 a.m. — angry and anxious. He also walked throughout the building, setting off alarms and adding to his agitation, she said.

Under the new system, Bill sleeps until midmorning. He is allowed free rein in the building and staffers are instructed to gently guide him back to his floor instead of sounding alarms.

“He’s been fine ever since,” Ledany said. “He doesn’t try to leave — he just liked being able to walk around.”

Other changes at the home include allowing residents to shower at a time they prefer, such as in the evening instead of the morning. Residents are allowed time to feed themselves, even if the process is painstakingly slow. And the residents who long for the days they were once nurses or other types of caregivers are allowed to assist with minor tasks, such as pouring drinks.

O’Keefe said she resisted embracing the new system at first. “I didn’t think this new way could be done, but I have to admit, it works,” she said.

A major bonus — the new system didn’t cost the home more, Katz said.

“We just reallocated the money we had,” Katz said. “For example, we realized that no one was showing up for the entertainment on weeknights, so we used that money to pay staff members to offer recreational activities in the late afternoon, when some residents were a little agitated.”

Will other nursing homes follow? Even if they start immediately, the system Buckingham uses will not show immediate results.

Paul Langevin, president of the Health Care Association of New Jersey, noted that the continuing cuts to Medicare and Medicaid funding to nursing homes will exacerbate the overprescribing of antipsychotics. It’s no coincidence, he said, that as Medicare reimbursements for nursing home care have dropped, the use of these medications has exploded.

“It takes a significant amount of time to sit down with someone and read to them to help calm them,” Langevin said. “Is that as efficient as giving him medication? It’s definitely a better outcome for him, but nursing homes have fiscal restraints.”

Indeed, while Buckingham managed to decrease the number of patients on these medications, other homes in North Jersey increased their use, according to a review of Medicare data from 2012. The nursing homes with the highest rates included Woodcrest Health Care in New Milford, where 32.4 percent of patients were on antipsychotics and Oak Ridge Rehabilitation and Nursing Center in Wayne, which medicated 31.9 percent of its residents. The Christian Health Center in Wyckoff reported that 27.6 percent of its patients were on antipsychotics.

Woodcrest officials defended the home’s record. “We have a very active program of working diligently in partnership with our physicians, those who actually prescribe medications, to reduce the use of antipsychotic medications for our residents, including those with complex behavioral and mental health issues in addition to their underlying Alzheimer’s and dementia,” Tim Hodges, a Woodcrest spokesman, said in a statement.

Dr. Mohamed Elrafei, a psychiatrist who serves as the medical director for Ramapo Ridge, a psychiatric hospital that is part of the Christian Health Center, said the home gave the drugs to dementia patients only as a “treatment of last resort.” He added: “When someone is severely agitated and may be a danger to himself or someone else and other medications aren’t working or can’t be used; they are used when it’s absolutely necessary.”

At Oak Ridge, Agnes Braxton, administrator of the center, said her home was “working to make adjustments and gradually taper off these medications. At one point, the center had been using the medications on 37.5 percent of its patients, according to the federal data.

“We work with one or two patients at a time and have an interdisciplinary team with a physician, nurse, pharmacist and others to reduce the medications, and then we watch to see whether it is damaging or helping the patient,” Braxton said. “We also try non-medication approaches such as increasing their activities and bringing in their family to find out what the patients liked to do in the past. Then we try to gear activities to what they used to do.”

There is no easy solution, administrators said. In fact, Linda Bowersox, vice president of clinical services at the Advanced Care Center at Lakeview in Wayne, said it was unlikely her home would ever be able to meet the 15 percent reduction set by the federal government— 23.1 percent of its patients were on these medications in 2012, according to federal data.

“I don’t think we’re going to get our number down much more than 18 percent,” she said.

“We work with two patients a month to try and reduce their medications — all the staff is on board,” she said. “Sometimes we’re successful and, honestly, sometimes we’re not.”

It’s not as simple as taking patients off their pills. Administrators say the only way to stop drugging patients is for homes to completely reimagine their approach to elderly care. That could require sweeping changes in everything from programs and staffing to the architecture of the facilities.

Sunni Herman, executive vice-president of the Jewish Home at Rockleigh, said her home has tried several new programs in the past year in an attempt to reduce their drug use from 25.5 percent.

“We’ve implemented non-medical programs … such as our Harp to Heart program, where we bought 20 harps that the residents can play,” Herman said. “We also purchased 50 iPods. … You can’t believe how it calms residents during periods of agitation.”

Long-term problem

Many patients have been drugged for years, like Chalupa, who, according to her daughter, suffered from dementia and was on a daily cocktail of medications, including the antipsychotic Zyprexa.

The drugs made her agitated and caused her to lash out. She had worn out her welcome at two other nursing homes by the time she got to Buckingham in 2005, her daughter said.

“A Catholic nursing home asked us to move her out because they couldn’t handle her — she was so disruptive,” Christin Chalupa said. The other was terrible, she said.

At Buckingham, she would have a few good weeks and then staff would notice her wearing her shower cap all day, O’Keefe said.

“That meant trouble was coming,” O’Keefe said. On more than one occasion, Chalupa was so cantankerous she would bring the staff to tears. She even called another nursing home and asked to be rescued, saying she was being held against her will.

“One day she threw a Tupperware bowl filled with soup at my head and yelled, ‘I’m not eating that crap you serve in the kitchen,’ ” O’Keefe said.

She didn’t even recognize her daughter. “I’d be afraid when I was driving here about what I would find — what she’d be like,” Christin Chalupa said.

In 2008, a psychiatrist began weaning Chalupa off Zyprexa and several other medications — including one for Parkinson’s, which she was taking even though she had never been diagnosed with the disease.

Slowly, she began to improve.

Now, despite her mother’s dementia, Christin Chalupa said this is the happiest and healthiest she’s seen her. Once rail thin, she has gained 30 pounds and never mentions that tooth. She dresses in color-coordinated outfits each day, complete with matching jewelry, and hasn’t reached for the shower cap or had a tantrum in years.

“She’s such a pleasure now,” Christin Chalupa said. “She’s a completely different Josephine.”