The Society of Critical Care Medicine has revamped its guidelines in an attempt to keep doctors from overprescribing benzodiazepines to sedate patients. “Benzos,” as they are sometimes called, are a class of anti-anxiety drugs including Valium, Klonopin and Ativan which can bring on a nightmarish set of side effects including delirium and hallucinations, even in the most clear-minded individuals.

These drugs have a heightened effect on the elderly, and are associated with an increased risk of falling.  For patients who are under the confusing influence of these drugs, painful medical procedures may feel more like torture.  A breathing tube can be interpreted as someone choking them.  A catheter insertion may seem like rape.  Often patients in this situation will later develop post-traumatic stress disorder, suffering nightmares, flashbacks, memory loss, and lingering phobias. They may feel confused and embarrassed about what they remember from their treatment.

Some treatment centers and families in Europe keep journals for their patients so that disturbing memories of hallucinations can be cross-referenced with the actual procedures which took place. While these journals seem to speed up mental recovery after a scary medical procedure, they have been slow to take hold in the United States.

See articles here, here, and here.

Antipsychotic medications have been used as a form of chemical restraint in many nursing homes, with some reporting as high as 37% of residents.  These drugs are often used in nursing homes to make residents more calm and easier to handle. This type of chemical restraint is often the result of understaffing and not enough training.   When prescribed to patients that don’t need them, they can have a long list of side effects, which include agitation, fatigue, and loss of awareness and speech.

An alternative to chemical restraint is redirection, but critics say it can be time consuming. When a patient becomes agitated, instead of giving that patient a drug which will make them become drooling, incontinent, or out of it, the nurse or aide can redirect the patient. This involves finding out about the patient, what they liked, what they used to do. In many cases, a patient becomes agitated because they are in unfamiliar surroundings and cannot do things that they have done all their lives, like take walks, or sleep in. It can be helpful to learn more about a patient than simply their medical history because it can allow caregivers to form a bond with the patient which can help them feel familiar. Utilizing permanent staff for residents is a key part of building trust with that resident. Unfortunately, permanent staff requires that staff stay at a facility, and many homes have high turnover rates because of their working and operating conditions.

Critics say that in addition to being time consuming and sometimes impossible, taking time to redirect residents and forge bonds with them is simply not feasible or practical. In an industry where costs are constantly being cut, with Medicare and Medicaid being reduced at every turn, staff are decreasing, budgets for activities are decreasing, and there’s been a direct connection to federal cuts and the increase of these medications.

Overmedication of residents is a common occurrence because the systems don’t encourage caregivers to take time with residents. To have a nursing home where chemical restraints aren’t used unless necessary requires a timely, if not necessarily costly, overhaul of the entire home. The system that’s in place isn’t friendly to these changes, and until caregivers have the time to spend with residents, chemical restraint is going to be an accepted if hushed practice in nursing homes across the globe.

See articles here and here.

The Hartford Courant had a great editorial recently about the off label use of antipsychotics in nursing homes.  Below are excerpts.

Antipsychotic drugs are prescribed too frequently in Connecticut nursing homes to keep patients who have dementia or mental illness under control.

Lisa Chedekel of the nonprofit Connecticut Health Investigative Team has reported that some nursing homes in this state significantly exceed the national rate of administering such drugs to long-stay residents. At some facilities, the rate is more than double the already high state average. At one nursing home, 68 percent of long-stay residents were getting antipsychotics.

Antipsychotic drugs are supposed to be given only to patients diagnosed as having a psychosis or related condition. But in many nursing homes, they are prescribed for those who are difficult to manage, regardless of whether there’s a diagnosis of a mental illness.

 

That’s not good for patients, and ought to be curbed. The U.S. Health and Human Services Department has urged taking action against inappropriate prescription. The state Department of Public Health is trying to develop ways to reduce the use of antipsychotic medications.

Critics say that nursing homes are tempted to overmedicate because agitated patients are easier to deal with when sedated. But there can be serious, perhaps fatal, side effects to giving these drugs to elderly people with dementia.

Many residents of long-term-care facilities are neither elderly nor frail, but mentally ill. In 1995, the state closed two of its three mental institutions — Fairfield Hills and Norwich State Hospital — and some residents ended up in nursing homes. They may need to be treated with antipsychotic drugs. Still, that doesn’t excuse prescribing medication without a proper diagnosis, as some nursing homes do. That must stop.

Increasing staff and training has been suggested as a way to lower the need to use medication — but those are expensive, and for facilities that rely on Medicaid reimbursement, the funding may not be adequate. This problem, as so many in health care, is linked to money.

Long-term solutions to overmedication should involve alternative ways to care for those with mental illness, perhaps in supervised group homes.

 

WNYC also had a recent article on the overuse of antipsychotics in New York City nursing homes. “There is widespread and poorly regulated use of anti-psychotic medications by several New York City nursing homes, according to a new investigation by the Gotham Gazette.” The series found that one-in-four nursing home residents in the city were given anti-psychotics in 2011, and one-in-three homes dose more than a third of their residents.

Anti-psychotics are sometimes known as “chemical restraints” because of their sedative effect. Under federal law, anti-psychotic drugs can only be given on doctors’ orders, and not so nursing home staff can better manage difficult patients.  They are frequently prescribed for difficult patients, such as those suffering from dementia. Yet research has found that the drugs can also lead to falls, strokes and even death.

 

The New Hampshire News had an interesting article about the “Battle Against Chemical Restraints in Nursing Homes”.  Nursing homes around the country are under pressure from the Federal government to reduce their use of antipsychotics.  This powerful class of prescription drug is meant for mental illnesses such as schizophrenia. But they are being used on people with Alzheimer’s Disease at startling rates.

MedPageToday also had an article stating that more than one in five U.S. nursing home residents are given antipsychotic medications — generally off-label, a national analysis revealed. In a sample of more than 1 million patients in nursing homes, 22% were given at least one prescription for an antipsychotic agent, according to Becky A. Briesacher, PhD, and colleagues from the University of Massachusetts in Worcester.  The researchers analyzed data on dispensing during 2009-2010 by the long-term care pharmacy Omnicare, which provides medication services across the country and for up to half of all residents.

The prescribing of antipsychotic medications persists at high levels in U.S. nursing homes despite extensive data demonstrating marginal clinical benefits and serious adverse effects, including death,” Briesacher and colleagues wrote in a research letter in the Feb. 6 issue of the Journal of the American Medical Association.  “The most common antipsychotics prescribed are often used for off-label indications related to dementia, and the extended durations of use raise concerns about the care of frail elders residing in [nursing homes],” the researchers stated.

In more than two-thirds of cases, the agents used were from the atypical class of antipsychotics, which are primarily indicated for the treatment of schizophrenia and bipolar disorder:

Quetiapine (Seroquel), 31.1%
Risperidone (Risperdal), 24.4%
Olanzapine (Zyprexa), 13.1%

Meanwhile, the Hartford Courant reported that the Westside Care Center nursing home in Manchester, two-thirds of long-stay residents are receiving antipsychotic drugs, even though they do not have a psychosis or related condition that regulators say warrants their use. Westside’s rate of dispensing the drugs to 68 percent of its residents without a diagnosis is the highest in the state, according to federal data — and more than double the state’s average of 26 percent, which already ranks in the top-third of states nationally.  The December data — newly disclosed by federal nursing home regulators — show that more than half of Connecticut’s nursing homes — 128 of 233 — were dispensing antipsychotics without a clinical diagnosis at rates exceeding the national average.

 

Medical News Today reported the finding that medications are known as nonbenzodiazepine hypnotic drugs, a class of sleeping medications that includes Lunesta, Sonata, and Ambien increase the risk of falls and hip fractures.  The scientists discovered that the risk for hip fracture was greater for the residents taking a nonbenzodiazepine hypnotic drug.  The benefits do not outweigh the risks.

The finding came from new research conducted by experts from Harvard Medical School, led by Sarah D. Berry, M.D., M.P.H.

It is important to understand the relationship between sleep medication use and injurious falls in nursing home residents,” the experts wrote. A previous study demonstrated that nursing home residents with dementia are three times more likely to have an injurious fall when they take drugs to treat depression.”

The authors said:
“The risk for hip fracture is elevated among nursing home residents using a nonbenzodiazepine hypnotic drug. New users and residents having mild to moderate cognitive impairment or requiring limited assistance with transfers may be most vulnerable to the use of these drugs.”
When prescribing sleeping pills to nursing home residents, doctors should take caution, the researchers added. They concluded :

“Residents, staff, and nursing home administrators need to collaborate to create a culture change within the nursing home that increases daytime activity, improves social engagement, avoids daytime naps, and minimizes awake time in bed for residents. Physicians must also have amore active role to ensure that sleep quality and structure are not impaired by treatable medical or psychiatric conditions and that other sleep disorders commonly seen in the frail elderly (eg, central sleep apnea) are promptly diagnosed and treated.”

 

Gwen D. Hughes, who worked at Kern Valley Healthcare District’s facility in Lake Isabella, was charged in the deaths of three patients. She pleaded no contest in Kern County Superior Court to one felony count of elder abuse with a special allegation that the abuse contributed to the victim’s death. She was only sentenced to three years in state prison for overmedicating patients at a Kern County nursing home, causing at least one wrongful death.   The California Department of Public Health first began to investigate the facility in 2007, following complaints from an ombudsman that a patient at the facility had been held down and forcibly injected with psychotropic medications.  See article at SFGate here.

Hughes ordered the hospital’s director of pharmacy to write doctor’s orders for psychotropic medication for 23 patients — not for therapeutic reasons, but to keep them quiet.  Officials say the drugs were given to patients who were noisy, prone to wandering, who complained about conditions or were argumentative.  The investigation found that the drugs hastened three patients’ deaths, and all 23 suffered adverse physical reactions.

Pamela Ott, the former chief executive officer of the Kern Valley Health District, pleaded no contest to one felony count of conspiracy to commit an act injurious to the public health, based on her failure to adequately supervise Hughes. Ott was sentenced to three years of formal probation.

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Medical Express had an interesting article  about a review in The Cochrane Library that found that education and social support for staff and caregivers can reduce the use of antipsychotics in nursing home patients with dementia.  Improved staff training and education, communication between personal and professional caregivers and support for everyone involved in the patient’s care are effective non-pharmacological methods to try before using antipsychotic medications.

Unfortunately nursing homes use antipsychotic drugs as the first line of treatment for any challenging behavior in nursing homes, despite the fact that they can have serious side effects including over-sedation, falls and cardiovascular problems.

“Despite the reduction in antipsychotic use with the behavioral interventions, none of the four individual studies found significant changes in the behavioral and psychological symptoms of dementia. I agree with the main findings but further research to study the effectiveness of non-pharmacological approaches to managing behavioral symptoms of dementia is sorely needed.”

 

 

WBIR had an article on the off label use of anti-psychotics in nursing homes.  Health officials believe that too many patients with dementia are being given antipsychotics in an “off-label” use to control behavior instead of treating their dementia symptoms through non-pharmacologic therapy. Prescribing antipsychotics – approved by the FDA to treat schizophrenia and bipolar disorder among conditions – can expose a patient to medical risks.  The FDA requires that the packaging on those drugs contain a “black box warning” that administering them to elderly dementia patients increases the chance of death and can have other harmful side effects.

State health officials in Tennessee say the overuse of antipsychotic drugs nursing homes, particularly on those diagnosed with dementia, is a huge problem. About 30 percent of long-term nursing home residents in Tennessee are given antipsychotics, according to statistics collected by the Centers for Medicare and Medicaid Services. The national average is 23.8 percent, which federal officials want cut by 15 percent by year-end.

Dispensing pills is an effort to silence residents who are “acting out” without trying to find the underlying cause.  However, this increases the risk of fatal falls.

 

Medical Express reported: “More than one in four older veterans residing in U.S. Department of Veterans Affairs (VA) Community Living Centers received antipsychotic medications, and more than 40 percent of those veterans had no documented evidence-based reason for use, according to new research from the University of Pittsburgh and VA Pittsburgh Medical Center.”

The study, the first to address this topic in VA nursing homes, finds similar rates of antipsychotic use as studies in non-VA nursing homes. The findings will be published in the November issue of the journal Medical Care and currently are available online.

“Our study adds to the growing evidence base that antipsychotics have been overused in nursing homes, and the VA is not immune to this problem,” said lead author Walid Gellad, M.D., M.P.H., an assistant professor in Pitt’s School of Medicine and the Graduate School of Public Health’s Department of Health Policy and Management. “Behavioral symptoms in dementia patients are difficult to treat, and, in most cases, nursing home staff are doing what they can to keep patients comfortable and safe. We have to find better ways to do this, though.”

Antipsychotics have limited efficacy in alleviating behavioral problems in dementia patients, and several studies associate their use with an increased risk of mortality.

 

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