Low Risk, Heavy Drugs

Hartford Courant, Hartford, CT, March 2, 2008

State's Nursing Homes Might Be Overusing Antipsychotics
BY LISA CHEDEKEL | Courant Staff Writer
Connecticut's nursing homes dole out antipsychotic drugs to residents who do not have psychotic disorders at one of the highest rates in the country, raising questions about whether the medications are being used to subdue agitated patients because of a lack of staffing and attention to alternate treatments.

Federal data from the Centers for Medicare & Medicaid Services show that since 2005, Connecticut has consistently ranked in the top four states in the prevalence of antipsychotic drugs dispensed to nursing home residents who have no psychotic or related conditions. In the most recent quarterly report, through September 2007, only Louisiana had a higher prevalence rate than Connecticut, where more than 26 percent of residents who lacked an appropriate psychiatric diagnosis were prescribed antipsychotics.

Nationally, the prevalence rate is 19.8 percent, with several states, such as Florida, Pennsylvania and New Jersey, well below that average.

"This is not a good indicator" for Connecticut, said Charlene Harrington, an expert on nursing home quality and professor of sociology and nursing at the University of California-San Francisco. "One of the main factors [for a high medication rate] is not having enough staff. If patients are having behavioral problems, it's easier to give them a pill to keep them quiet" than to hire more staff. "It's cheaper. They'll sleep a lot."

Nursing-home staffing is now a focus of state lawmakers, who are weighing proposals that would update the state's minimum staffing standards to nationally recommended levels. The existing standards are more than 25 years old and rank among the least stringent in the country. The staffing proposals were prompted by a series in The Courant that detailed the troubled patient-care and financial history of one of the state's largest chains, Haven Healthcare, which filed for bankruptcy after the stories appeared.

Federal data from the past three years show that Connecticut has ranked highest or second-highest among states in the prevalence of antipsychotic use among "low-risk" nursing home residents, defined as those who do not exhibit cognitive impairment and behavioral problems. In the most recent reporting period, 23.3 percent of low-risk residents were receiving antipsychotics, compared with the national average of 16.5 percent.

Among "high-risk" residents who do exhibit those problems, Connecticut prescribes antipsychotics at the highest rate in the country ― 55.2 percent, compared with the national average of 42.5 percent, according to data from the most recent reporting period.

The Nursing Home Reform Act of 1987 mandates that residents be free from "chemical restraints" imposed for the purposes of discipline or convenience. Federal guidelines allow nursing homes to administer antipsychotic drugs to residents with dementia-related behavioral symptoms, but they require that residents meet specific clinical criteria and receive gradual dose reductions and behavioral interventions in an attempt to wean them off the medications.

Although the newer antipsychotics, called atypicals, are approved only for bipolar disorder and schizophrenia, doctors routinely prescribe them "off-label" to quiet behavioral problems associated with dementia or Alzheimer's disease. The use of such drugs in nursing homes has grown in recent years, despite studies questioning their benefits and highlighting their risks.

The most commonly prescribed antipsychotics carry Food and Drug Administration "black box" warnings that elderly dementia patients using them face an increased risk of death. In addition, studies have shown that the drugs most commonly prescribed off-label for Alzheimer's patients are no more effective than placebos for most people, and carry side effects that include confusion, sleepiness and rigidity, which can increase the risk of falls.

State public health officials say they are not sure why Connecticut nursing homes have a high rate of dispensing antipsychotics to residents who lack an appropriate diagnosis. They say that their prevalence data might be better reported than other states, and they note that the health department has been aggressive about citing homes for medicating residents unnecessarily.

Some health officials suggest that the prevalence rate is high because Connecticut has a relatively large proportion of residents who are over age 80 and who have dementia-related problems.

"One of the reasons could be we have a large number of seniors in our [nursing home] population. Our population is getting older. Our dementia numbers are probably increasing," said Barbara Cass, the state health department's program manager for the Medicare survey program.

But Connecticut nursing homes do not have especially high numbers of residents diagnosed with dementia or other psychiatric conditions in comparison with other states, according to federal data. In 2006, 46 percent of Connecticut's nursing home residents had a dementia diagnosis ― slightly higher than the national average of 45 percent, but lower than 22 other states. About 15 percent of Connecticut's nursing home residents had other psychiatric diagnoses, lower than the national average of 20.5 percent.

Those figures account for residents with specific diagnoses, but they do not include all residents who exhibit dementia-related behavioral problems.

Dr. Harry Morgan, a geriatric psychiatrist in Glastonbury, said he was disturbed to learn that Connecticut ranks high in its rate of dispensing antipsychotics to residents without diagnoses. He said that the protocol he advocates as a consultant to nursing homes calls for clinicians to try behavioral interventions and examine possible physical causes for agitation before considering antipsychotics.

"There are times in which patients with dementing illnesses are in such distress, to do nothing would be inhumane," Morgan said. "But in some nursing homes, what you see is a knee-jerk reaction ― they'll put someone on a neuroleptic [or antipsychotic] … in hopes of a quick fix tonight."

"The use of these medicines can be appropriate, but it is not appropriate to use them as an alternative to adequate staffing," Morgan said. "People shouldn't approach them as a first-line treatment. …We have to work to drive down the usage of antipsychotic drugs."

Toby Edelman, an attorney with the Center for Medicare Advocacy Inc. in Washington said that in the 20 years since the nursing-home reform law was passed, the industry has focused more on reducing the prevalence of physical restraints than on limiting chemical restraints.

Medication "is not as visible as physical restraints, so it's used as a substitute," Edelman said. "That's hardly what the [reform act] was intended to do."

Edelman and Harrington said that a high prevalence of antipsychotic use in a nursing home can be an indicator of inadequate staffing. Non-pharmacological interventions for residents with dementia, such as recreational activities, exercise and one-on-one attention, require extra staff.

"You have to have the time to spend with people," Harrington said.

On average, nursing homes in Connecticut provide about 3.7 hours of care per resident a day ― 1.4 hours by licensed or registered nurses, and 2.3 hours by certified nursing assistants.

Other states have taken steps to boost staffing to levels recommended in a study commissioned by the federal government: 4.1 hours of care per resident a day.

Connecticut homes have had little incentive to boost staffing, in part because state law requires only 1.9 hours of nursing care a day. The state health department has rarely ordered individual homes to increase their staffing levels.

But federal data do suggest that Connecticut is more aggressive than other states in citing nursing homes for administering unnecessary antipsychotic drugs and other medications.

In the latest surveys, state health inspectors cited 21.7 percent of Connecticut's 244 licensed homes for administering "unnecessary drugs" to residents, a rate higher than the regional average of 14.7 percent and the national average of 18 percent. Although unnecessary drugs can include all kinds of medication, the citation frequently is issued for improper use of psychoactive drugs.

Cass, the health department program manager, said that Connecticut has been "very astute" in identifying unnecessary drug violations, in part because the state uses a more in-depth inspection process than many other states. In each nursing home, inspectors closely review the medication records of a sampling of residents to ensure that there are appropriate diagnoses, she said. In addition, the health department flags homes with high rates of prescribing antipsychotics and conducts "more focused reviews" of those facilities.

Inspection data show that the state has issued more than 110 citations to nursing homes since October 2005 for administering unnecessary drugs. Eleven homes have been cited twice for that violation, with the second citation coming within a year of the first. Among the homes cited twice was Wethersfield Health Care Center, which was included on a recent federal list of 54 of the most poorly performing nursing homes nationwide.

Eight homes owned by Haven Healthcare have been cited for unnecessary drugs in the past two years, federal records show. Haven's chain of 15 Connecticut homes filed for bankruptcy in November after The Courant's stories detailed the chain's repeated patient-care deficiencies, lower-than-average staffing and serious financial problems.

The improper use of psychotropic drugs at one Haven home in Torrington led the health department to issue a consent order against the home in December 2006 that mandated closer monitoring of residents receiving antipsychotics. State health inspectors had cited the home for seven cases in which it failed to justify the use of antipsychotic, antidepressant or sedative medications, or to monitor residents for side effects.

In one of those cases, a resident receiving five such medications, without an appropriate diagnosis, was found to be in such declining health that hospice was called ― until a physician was alerted and ordered a reduction in the drugs. The resident's mental state then rebounded: "The agitation and anxiety are gone, the resident is much more alert [and] vital signs are stable," the state health inspection report says.

More recently, in November 2007, state health inspectors imposed a consent order and two years' probation on Haven's home in New Haven for myriad violations, among them failing to justify and monitor the use of antipsychotic medications prescribed to two residents. The New Haven home also was cited for low staffing levels.

Nationally, the rate of prescribing psychoactive drugs in nursing homes has been rising in recent years, with a 2005 study showing that antipsychotic use in 2000-01 had reached the highest level in more than a decade. That study, headed by a University of Massachusetts Medical School researcher, found that about one-third of nursing home residents receiving antipsychotics had "inappropriate indications" for the drugs.

In 2005, the taxpayer-funded Medicaid program ― the main payer for drugs prescribed in nursing homes ― spent more than $5 billion on antipsychotics such as Risperdal and Seroquel, which retail for several dollars per pill.

Since the FDA warnings, some doctors increasingly have turned to antidepressants to treat the agitation and psychotic symptoms associated with dementia. Morgan said that depression can be an underlying cause of agitation, and he noted that antidepressants don't carry the adverse side effects ― or expense ― of antipsychotics.

Morgan said that although most Connecticut nursing homes have a large proportion of residents with dementia-related symptoms ― 50 percent to 70 percent, in his estimation ― many homes "don't think of themselves as dementia-care facilities, in terms of having special expertise" or extensive training for staff. That needs to change, he said.

"We have to begin to shift the model of dementia care away from skilled-nursing facilities, so that we also focus on behavioral interventions [and] recreational and interpersonal activities," Morgan said. "Staffing certainly has to be looked at, but so does the training of that staff."

Contact Lisa Chedekel at lchedekel@courant.com.

Original article from Hartford Courant:
http://www.courant.com/news/health/hc-druggedresidents0302.artmar02,0,3873896,full.story