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Nursing Homes' Drug Use Falls

Original source:

Wall Street Journal
Lucette Lagnado
Aug. 26, 2013

A two-year effort by the federal government and the nursing-home industry has reduced the use of powerful antipsychotic drugs among elderly nursing-home residents, but the decline fell short of the program's goal, according to U.S. officials.

The percentage of patients receiving antipsychotics fell to 21.7% in the first quarter of 2013 from an average of 23.9% in the last quarter of 2011—a 9% decrease, according to data the Centers for Medicare and Medicaid Services is expected to release as early as this week.

When CMS, which oversees spending on the big federal health-care programs for the elderly and poor, embarked on its effort to work with the nursing-home industry to cut the use of such drugs, the agency's goal was for nursing homes to achieve a 15% reduction in the rate of usage by the end of 2012.

The effort came amid fears that antipsychotic drugs were being overused, especially on the elderly with dementia or Alzheimer's, to whom the drugs pose a potentially higher risk of death. In recent years, the rise of a new type of antipsychotic known as atypicals—originally hailed as having fewer side effects and sold under names like Risperdal, Seroquel, Zyprexa or Abilify—coincided with their growing use among people in nursing homes.

There are about 1.5 million nursing-home patients in the U.S, according to CMS.

Antipsychotics are costly to Medicare, the health-insurance program for the elderly and disabled. In 2011, Medicare Part D, which pays for Medicare prescriptions, spent $7.6 billion on this class of drugs, CMS says.

In 2011, the Inspector General of Health and Human Services issued a tough report about use of antipsychotics in the elderly, finding that 88% of the time, the drugs had been prescribed to patients suffering from dementia—a situation he later said was "potentially most alarming."

Federal officials expressed satisfaction with the results and said they hope nursing homes will achieve the 15% decline in the rate of usage by year's end.

"We set a national goal to decrease antipsychotics and we have made really dramatic progress working with stakeholders," said Dr. Patrick Conway, chief medical officer for CMS.

Dr. Conway said his agency worked with the industry, providing guidance on a more "patient-centered" approach, in which homes try to address a resident's distress without medication. He said oversight has been bolstered with "boots on the ground" and that home inspectors have received training to help them target antipsychotic use when checking a facility.

But critics of the widespread use of antipsychotic drugs said the results call for a tougher approach by the government. "It is good, it is better, but it is still so outrageously high," said Toby Edelman, senior policy attorney at the Washington, D.C., office of the Center for Medicare Advocacy, a nonprofit working on behalf of Medicare beneficiaries.

The federal Food and Drug Administration in 2005 imposed its strongest warning label, a "black box," on all packages of atypicals, saying that elderly patients with dementia face an increased risk of death from the drugs. It later expanded the warning to older antipsychotics.

"These drugs are estimated to increase risk of death by 60% to 70% in elderly patients with dementia, based on results of 17 randomized clinical trials enrolling more than 5,000 patients," said Stephen Crystal, a health researcher at Rutgers University.

Representatives of AstraZeneca PLC, maker of Seroquel; Eli Lilly & Co., which makes Zyprexa; and Otsuka Pharmaceutical Co., maker of Abilify; said their drugs aren't indicated for use in elderly patients with dementia-related psychosis. Janssen Pharmaceuticals Inc., a unit of Johnson & Johnson that makes Risperdal, said it wouldn't comment.

Dr. Cheryl Phillips, a senior vice president at LeadingAge, an industry group whose members include nonprofit nursing homes, said the industry is "approaching a tipping point of change" in efforts to cut reliance on antipsychotics.

Nursing-home officials say inadequate staffing prompts some facilities to give sedating drugs. "Unfortunately a lot of nursing homes would rather give someone a pill to pacify them" instead of hiring more workers, said Morris Kaplan, owner of Gwynedd Square Nursing Center in Lansdale, Pa. His home, he said, went from a 13.8% rate in July 2012 to 10% in July 2013.

Officials at AG Rhodes Health & Rehab of Cobb, a 130-bed home in Marietta, Ga., said nurses were taught that with an agitated patient they should rule out the obvious, like whether they were in pain or hungry. The effort needed a "totally different mind set," said Jackie Summerlin, director of clinical services. The home has gone from 30 residents on antipsychotics to nine.

Write to Lucette Lagnado at