This morning's Boston.com (registration required) has an important, and deeply troubling, article concerning the rampant overuse of anti-psychotic medication by Massachusetts nursing homes to manage the behaviors of residents with dementia.These drugs have not been approved by the Food and Drug Administration (FDA) for this purpose, and in fact, most have a “black box” warning indicating that they increase the risk of death for patients with dementia. Nevertheless, it seems clear that there's a correlation between the use of the drugs and the staffing levels at the facility:
Two years ago, the Globe reported that Massachusetts was among the states with the highest percentage of nursing home residents receiving antipsychotics for conditions not recommended by regulators. The newspaper then requested data on antipsychotic use at all 15,600 nursing homes nationwide from 2005 to 2010, the most recent numbers available.
Late last year, the Centers for Medicare & Medicaid Services released the data, which the newspaper analyzed along with information on other characteristics of the roughly 1.1 million long-term residents of US nursing homes. (Homes with fewer than 50 residents were excluded from the analysis.)
Among the Globe's findings:
■ In 21 percent of US nursing homes in 2010, at least one-quarter of the residents without illnesses recommended for antipsychotic use received the medications. In Massachusetts, the proportion was 28 percent.
■ There is a clear link between the rate of antipsychotic use in a nursing home and its staffing level. Homes that most often used these drugs for conditions not recommended by regulators had fewer registered nurses, who direct care, and nurses' aides, who provide most of the hands-on care. Nursing home specialists say it can be more time-consuming for staff to keep dementia patients calm without using drugs.
■ The data do not include the reasons why patients received antipsychotics, but homes that most often used them for conditions unrelated to a psychosis tended to have more residents deemed by staff to have behavioral problems, including wandering, being verbally or physically abusive, or resisting care.
■ These homes also had a greater percentage of residents covered by the government Medicaid program, which pays nursing home bills for people with limited incomes or who have exhausted their savings. They also have fewer residents with private insurance, which pays a much higher rate than Medicaid to nursing homes. That means these homes have less money to hire staff.
The newspaper's analysis shows there has been some improvement. Prescribing of antipsychotics for residents without a condition recommended by nursing home regulators has fallen nationally and in Massachusetts since 2005, the year the FDA issued the first of its two warnings against use of the medications in elderly patients with dementia.
As a health care agent or a guardian, you need to be asking questions — both before admission and afterwards — about these medications, their risks, how frequently does the facility try to reduce their usage and does that reduction actually happen, Is there enough staff to provide care, and how well trained are those staff in redirecting behavior? Does that training extend to the night and weekend staff? Do staff actually look for underlying causes (such as a urinary tract infection or sleep apnea) and try to treat those causes before resorting to medication.
You should also look at the environment from the perspective of the dementia patient. Is the atmosphere comforting? How noisy is it? Do residents seem to be spending most of their time in bed or sitting in the hallway, or are they engaged in activities?
The Alzheimer's Association has a free CareFinder tool which can be used to help you customize the questions you should be asking of any facility. You'll need to give yourself enough time to complete the questionnaire, but the result should be well worth it.
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