Are Nursing Homes Over-Medicating Patients?
By James T. Mulder, The Post-Standard July 30, 2012
Syracuse, N.Y. -- About one-third of Central New York’s nursing homes have higher than average numbers of patients on antipsychotic drugs - medications that can be deadly for elderly people with dementia.
The federal government earlier this month started publicly reporting antipsychotic medication use for every nursing home in the nation. The Centers for Medicare and Medicaid Services - CMS for short - is shining a light on the issue as part of an effort to get nursing homes to curb the use of these drugs with dementia patients.
Antipsychotic drugs are designed to treat major mental disorders and mood disorders. They have been approved by the U.S. Food and Drug Administration to treat schizophrenia and bipolar disorder.
The FDA issued a warning in 2005 that the use of these drugs by elderly people with dementia increases their risk of death. The FDA made manufacturers of these drugs include this warning on product labels.
Even though the drugs are not approved for dementia, doctors are allowed to prescribe them on an "off-label" basis for people with dementia and other conditions.
A CMS analysis shows nearly 40 percent of nursing home patients with signs of dementia were receiving antipsychotics at some point in 2010 and that 17 percent of nursing home patients were getting excessive doses.
A 2011 report by the Department of Health and Human Services Office of Inspector General found nearly nine of every 10 Medicare claims for antipsychotic drugs for nursing home patients were for elderly people with dementia. Medicare is the federal health insurance program for people 65 and older and the disabled. It paid out more than $309 million in claims for antipsychotic drugs for nursing home patients during the first six months of 2007, according to the inspector general’s report.
"Government, taxpayers, nursing home residents, as well as their families and caregivers should be outraged and seek solutions," Daniel R. Levinson, inspector general of Health and Human Services, said last year when the report came out.
The federal government has accused Omnicare Inc., a pharmacy company that caters to nursing homes, and drug manufacturer Johnson & Johnson of colluding to promote antipsychotic drug use in nursing homes.
The government reached a $98 million settlement with Omnicare in 2009 to resolve allegations that it received kickbacks to recommend antipsychotics for use in nursing homes. The federal government has accused Johnson & Johnson of paying millions of dollars in illegal kickbacks to Omnicare to increase sales of Risperdal, an antipsychotic drug.
The Wall Street Journal recently reported Johnson & Johnson has agreed to pay as much as $2.2 billion to resolve a federal investigation into its marketing of Risperdal.
CMS wants nursing homes to cut antipsychotic drug use by 15 percent this year.
At Central New York nursing homes, the percentage of long-term residents on antipsychotics ranges from 6.6 percent to 37.7 percent. The state average is 21.7 percent and the national average is 23.9 percent.
CMS publishes the numbers on its Nursing Home Compare website. (http://www.medicare.gov/NursingHomeCompare/search.aspx?bhcp=1&AspxAutoDetectCookieSupport=1)
CMS says the lower a nursing home’s percentage, the better. A high number, however, does not necessarily mean a nursing home is administering these drugs inappropriately, said Carolina Fortin-Garcia, an agency spokeswoman.
"The intent is to put that information out there so you can ask your nursing home about it," she said.
Richard Mollot, of the Long Term Care Community Coalition, a New York City-based group that advocates on behalf of nursing home residents, said the drugs are often used as chemical restraints to sedate patients, especially in nursing homes short on staff.
"People want their loved one comforted, but this is not comforting,” Mollot said. “The person can become locked into an almost catatonic state."
Dr. Sharon Brangman, chief of geriatrics at Upstate Medical University, said while some nursing homes use the drugs inappropriately, the medications can be effective to temporarily manage behavior problems of Alzheimer’s patients when administered in small doses and carefully monitored.
The drugs can be helpful, for example, if an Alzheimer’s patient is having delusions, screaming, cannot eat or sleep and is disturbing others, she said.
"If these medications are completely removed from our ability to manage these behaviors and there is no good alternative, we could be posing a lot of harm to patients," said Brangman, past president of the American Geriatrics Society.
The drugs should not be used to sedate people into submission or stop people from wandering, fidgeting or trying to climb out of bed, she said.
Nursing homes do not prescribe the drugs - their doctors do.
One of the biggest problems is most nursing homes are staffed by doctors without training in geriatric medicine, Brangman said. Geriatrics is the branch of medicine focused on the diagnosis, treatment and prevention of disease in older people.
Many nursing home doctors have not been trained to correctly prescribe antipsychotic drugs, she said.
"We want all doctors to have appropriate training, but it’s hard to retrofit doctors already out there in practice," Brangman said.
The public cannot draw any conclusions about a nursing home based on the new numbers published by CMS, according to Brangman. That’s because some nursing homes have higher proportions of patients with schizophrenia, she said.
Howd Nursing Home, a 40-bed nursing home in Moravia, has 37.7 percent of its residents on antipsychotics - the highest number of any nursing home in Central New York.
"If you just look at the numbers you get the impression we are chemically restraining people," said Stan Wojeiechowski, the home’s consulting administrator.
The number is high because most of the home’s residents are younger people with schizophrenia, bipolar disorder and depression, but not dementia, he said.
The use of antipsychotics with these patients is justified, he said.
"It’s difficult to get people off these because their behaviors can deescalate very quickly on the wrong doses and they can become a threat to themselves and others," Wojeiechowski said.
At Van Duyn, Onondaga County’s 513-bed nursing home on Onondaga Hill, 29.3 percent of patients are on antipsychotics.
"Van Duyn is a safety net facility and we take a larger proportion of residents with psych diagnoses," said Ann Rooney, deputy county executive for human services.
Crouse Community Center, a 120-bed nursing home in the Madison County town of Nelson, has 30.1 percent of its patients on antipsychotics.
More than half the patients at Crouse have Alzheimer’s or dementia, said William Conole, the center’s administrator."From our vantage point, some of these drugs work well," he said.
But Crouse is looking at ways to reduce antipsychotic use by using different medications and non-drug approaches to address behavior issues, he said.
CMS encourages nursing homes to use non-drug strategies with dementia patients such as consistently assigning the same staff to patients, increasing exercise or time outdoors, monitoring and managing pain, and planning more activities.
Mollot of the Long Term Care Coalition advises people shopping for nursing homes to ask nursing home officials what approaches they use to provide good dementia care.
"Don’t just dope them up," he said.