Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.
If you have a friend or a loved one in a nursing home, you should be aware of one of the more insidious practices facing many residents. They can save the nursing home money but they rob patients of what remains of their spirit, dignity and independence.
It’s not easy for residents, especially newcomers, to come to terms with being in a nursing home, especially if they are relatively healthy, ambulatory and generally of sound mind. But if they’re restless, troubled and a bit depressed (and who wouldn’t be), too many nursing homes will take measures that can be debilitating.
Instead of helping unsteady residents go to the restroom when they need to, attendants often will fit them with diapers as a matter of routine because there’s not enough staff to tend to every resident’s needs when they need to go to the toilet quickly. And staff members don’t want to be blamed for a fall.
Worse, if an elderly patient who is rebelling against being in the home and its restrictions or rules, or is unruly, the staff may get a doctor to prescribe a sedative. Only the worst of homes will use physical restraints which are forbidden by law, but more often – too often – nursing homes are resorting to anti-psychotic drugs for residents who are not psychotic but suffering from dementia, anxiety or a show of anger and impatience with being confined.
In January 2007, according to the Center for Medicare Advocacy, a nursing home ombudsman reported to the California Health Department that a resident at a skilled nursing facility had been held down and forcibly injected with an anti-psychotic drug. The patient was not psychotic, but suffering from dementia and Alzheimer’s disease. An investigation, said the Center,
“determined that 22 patients, including some who were suffering from Alzheimer’s...were being given high doses of psychotropic medication not for therapeutic reasons but to simply control them for the convenience of the staff.”
This investigation, which may include criminal prosecutions, is still underway, but the problem persists elsewhere.
The Boston Globe reported on March 8 that 2,500 nursing home residents in Massachusetts were given “powerful anti-psychotic drugs last year that were not intended or recommended for their medical condition.” The drugs were intended and licensed by the Food and Drug Administration for people with severe and diagnosed mental illnesses such as schizophrenia or bipolar disorder.
But the FDA has sought to discourage the use of these drugs for dementia, a gradual loss of memory or anxiety, by issuing what is known as “black box” warnings on the inappropriate uses for the drugs. But warnings are often ignored by doctors who serve nursing homes and are not usually available, or by short-handed nurses and poorly paid or trained attendants who tend to too many demanding patients.
Toby Edelman, a senior attorney for the Center told me, “Anti-psychotic drugs are used because there’s not enough staff and facilities. They know they shouldn’t use physical restraints. Using drugs inappropriately as chemical restraints is less visible, but has the same effect.”
“The misuse of anti-psychotic medications in the treatment or control of nursing home residents is pervasive,” said the Center. “In the fourth quarter of 2009, the federal government reports that 26 percent of the nation’s 1.4 million nursing home residents –354,900 people – received anti-psychotic drugs...frequently for reasons not approved by the FDA.“
In February, 2007, Dr. David Graham, an FDA official, told a congressional committee that as many as “15,000 elderly people in nursing homes (are) dying each year from the off-label (not FDA approved) use of anti-psychotic medications for an indication that FDA knows the drug doesn’t work.”
The drugs include Seroquel, Risperdal and Zyprexa, which replaced an older drug, Haldol. The use of these chemical restraints is not all the fault of besieged nurses and aides. Last November, Omnicare, the nation;’s largest nursing home pharmacy agreed to pay $98 million and its supplier-drug manufacture paid $14 million because of a kickback scheme involving Johnson & Johnson’s drug Risperdal. The scheme allowed Johnson & Johnson to push the sale and use of the drug.
On March 10, Bloomberg News reported that despite the FDA warnings on the possible misuse of Risperdal, the largest selling drug of its kind, Johnson & Johnson made plans to reach $302 million in geriatric sales of the drug for this year claiming it was safe and effective. According to Bloomberg, unsealed documents in a lawsuit by Louisiana against the company disclosed “a J&J business plan...called for increasing the drug’s market share for elderly dementia sales, an unapproved use.”
In January 2009, Eli Lilly agreed to pay fines of $1.4 billion for illegally pushing the sales and off-brand use of its anti-psychotic drug, Zyprexa. According to the U.S. Justice Department, the company promoted the use of Zyprexa by claiming it would help facilities sedate resident who would otherwise require more care.
Nursing homes are handsomely paid by Medicaid, long term care insurance or by the resident. Numerous studies have found that residents get better care in not-for profit homes.
With these drugs at hand, physicians are often unaware of the possible side effects on people who are not psychotic. But then, the Center notes, physicians who are supposed to supervise patients often prescribe without seeing them.
Psychiatrists are rarely available except for the most troubled residents. Edelman said that nursing home and the long term care pharmacies rely on “chart orders” left by doctors when they are unavailable.
“Physicians are present in nursing homes only intermittently,” Edelman said, They do not have offices, they work out of their cars.”
The Center and other patient advocates seek federal legislation to enforce existing law requiring that a physician be on call and available when a patient requires prescription drugs.
Nursing homes and pharmacies argue that if federal law is not amended to allow “chart orders,” residents will not get pain medications they need. But anti-psychotic drugs are not mere pain killers. They can turn an anxious or slightly depressed or forgetful patient into a zombie.
And the easy access to painkillers can tempt staff members into overusing or even stealing them for their own use. That’s why the Drug Enforcement Agency has been involved in the effort to reduce the availability and use of these drugs on unsuspecting patients.
Said Edelman, the Center’s concern “speaks to the dangers of indiscriminate use of pain medications and the lack of physicians to detect and respond to life-threatening problems involving their use.”
Got a friend or loved one in a nursing home? If he or she is asleep most of the time or non-responsive, demand to know the drug that’s been used and question why. If there is no satisfactory answer, complain to the home’s ombudsman or contact the Center for Medicare Advocacy.
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