Mass. aims to cut drug overuse for dementia Effort targets nursing homes

The Boston Globe
By Kay Lazar
November 18, 2010

State regulators and the Massachusetts nursing home industry are launching a campaign today to reduce the inappropriate use of antipsychotic medications for residents with dementia — a practice that endangers lives and is more common here than in most other states.

During the next year, a team of specialists will identify nursing homes with successful methods for avoiding overuse of antipsychotics and determine which homes need help cutting back. Nursing home staff will be taught how to deal with aggressive and difficult behaviors, often displayed by dementia patients, without resorting to antipsychotics to sedate them.

In 2009, 22 percent of Massachusetts nursing home residents who received antipsychotic medications did not have a diagnosis for which the drugs were recommended — the 12th highest rate of inappropriate antipsychotic use in the nation, the Globe re ported earlier this year.

Twice in the past five years, federal regulators have issued nationwide alerts about troubling and sometimes fatal side effects when antipsychotics are taken by people with dementia, often Alzheimer’s patients.

Specialists say that understaffing sometimes prompts overuse of these medications to help control dementia patients’ behavior, but that inappropriate use can also be traced to lack of training in alternative approaches.

“There is a knowledge gap between the front-line workers — the nurses — and the black-box warnings on these medications,’’ said Laurie Herndon, a geriatric nurse practitioner who is leading the initiative for Massachusetts Senior Care, the trade group representing the state’s 430 nursing homes. A black-box warning is the most serious type of caution used in prescription drug labeling.

“We wanted to avoid talking at them, and instead provide educational material they can use,’’ Herndon said.

Campaign details will be unveiled at the association’s annual meeting today in Worcester, which is expected to draw about 900 people.

Alice Bonner, the state’s top nursing home regulator, said she appointed a task force to study the overuse of antipsychotics in nursing homes and develop alternative approaches after the Globe highlighted the problem in Massachusetts earlier this year. The task force includes nursing home physicians, nurses, social workers, and pharmacists, along with elder advocates, researchers, and state surveyors who monitor the quality of the facilities.

Bonner, director of the Bureau of Health Care Safety and Quality in the Department of Public Health, said the state, given its budget problems, does not have new resources to devote to the campaign, but is working with legislators and the Patrick administration to get new funding in the next state budget. The trade association intends to apply for grants from nonprofit groups to fund the initiative.

“No one is going to plunk a whole lot of money in our laps,’’ Herndon said, “but that shouldn’t stop us.’’

Bonner said that the task force has already identified low-cost approaches used by some nursing homes. One approach involves more careful screening of patients when they are admitted, which includes gathering more detailed information from families about the patient’s personality before the onset of illness. This, Bonner said, helps staffers tailor care and activities to each patient.


“They get a good sense of who a person was before they began to suffer with dementia, what kinds of things they like to do, and what kinds of things their family can tell us makes them calm or gets them engaged,’’ Bonner said.

“When you see a nursing home with a low rate of antipsychotics, very often you will see these programs,’’ she said.

Bonner also said that nursing homes that give workers consistent schedules that allow them to work with the same patients have also been successful.

“That helps reduce difficult behaviors with patients with dementia because staff knows the patients so well, they pick up on early signs of trouble and prevent a catastrophic event, so they can intervene early,’’ she said. Consistent schedules have the side benefit of helping nursing homes retain their workers longer, Bonner said. “Once this is in place, it turns out it is less expensive because staff turnover is expensive,’’ she said.

The education campaign will draw on the work of Dr. Susan Wehry, a geriatric psychiatrist and associate professor of psychiatry at the University of Vermont College of Medicine. Wehry recently concluded an intensive, nine-month pilot project in four Vermont nursing homes that taught all staffers, from housekeepers to medical directors, alternative approaches, such as using music and massage, to manage difficult patient behaviors.

The program, she said, helped identify which alternatives work, which don’t, and how challenging the mission can be.

Wehry is still analyzing the results but said preliminary findings showed that in one of the homes where the administrator made all of the training sessions mandatory for staff, antipsychotic use was dramatically reduced. A third of the patients with dementia had been prescribed antipsychotics before the program, and not one was on them by the end, she said.

“They were much improved in terms of staff-resident interactions and level of alertness,’’ Wehry said. “And they looked happier.’’

Data from another home that did not make all of the training mandatory showed no change in the number of dementia patients given the medications. Wehry said a more troubling trend also emerged there — one of the physicians switched from giving antipsychotics to prescribing antianxiety medications.

“If all we do is shift the burden, then all we have done is create a different set of problems,’’ Wehry said. “Our goal is not to just reduce our reliance on antipsychotics, but to change [patient] behaviors.’’

Bonner said that the task force has already identified low-cost approaches used by some nursing homes. One approach involves more careful screening of patients when they are admitted, which includes gathering more detailed information from families about the patient’s personality before the onset of illness. This, Bonner said, helps staffers tailor care and activities to each patient.


“They get a good sense of who a person was before they began to suffer with dementia, what kinds of things they like to do, and what kinds of things their family can tell us makes them calm or gets them engaged,’’ Bonner said.

“When you see a nursing home with a low rate of antipsychotics, very often you will see these programs,’’ she said.

Bonner also said that nursing homes that give workers consistent schedules that allow them to work with the same patients have also been successful.

“That helps reduce difficult behaviors with patients with dementia because staff knows the patients so well, they pick up on early signs of trouble and prevent a catastrophic event, so they can intervene early,’’ she said. Consistent schedules have the side benefit of helping nursing homes retain their workers longer, Bonner said. “Once this is in place, it turns out it is less expensive because staff turnover is expensive,’’ she said.

The education campaign will draw on the work of Dr. Susan Wehry, a geriatric psychiatrist and associate professor of psychiatry at the University of Vermont College of Medicine. Wehry recently concluded an intensive, nine-month pilot project in four Vermont nursing homes that taught all staffers, from housekeepers to medical directors, alternative approaches, such as using music and massage, to manage difficult patient behaviors.

The program, she said, helped identify which alternatives work, which don’t, and how challenging the mission can be.

Wehry is still analyzing the results but said preliminary findings showed that in one of the homes where the administrator made all of the training sessions mandatory for staff, antipsychotic use was dramatically reduced. A third of the patients with dementia had been prescribed antipsychotics before the program, and not one was on them by the end, she said.

“They were much improved in terms of staff-resident interactions and level of alertness,’’ Wehry said. “And they looked happier.’’

Data from another home that did not make all of the training mandatory showed no change in the number of dementia patients given the medications. Wehry said a more troubling trend also emerged there — one of the physicians switched from giving antipsychotics to prescribing antianxiety medications.

“If all we do is shift the burden, then all we have done is create a different set of problems,’’ Wehry said. “Our goal is not to just reduce our reliance on antipsychotics, but to change [patient] behaviors.’’

Nursing Home Drug Use Puts Many at Risk, Antipsychotics given to some with dementia

The Boston Globe
By Kay Lazar, Globe Staff
March 8, 2010

Nearly 2,500 nursing home residents in Massachusetts were given powerful antipsychotic drugs last year that were not intended or recommended for their medical condition, a practice that is more common here than in most other states, according to a Globe analysis of federal data.

Data collected by the federal Centers for Medicare and Medicaid Services show that 28 percent of Massachusetts nursing home residents were given antipsychotics in 2009. Of that group, 22 percent - or 2,483 - did not have a medical condition that calls for such treatment.

That rate was the 12th highest in the nation, according to the federal data.

The use of such drugs is especially worrisome in nursing homes because a substantial number of residents suffer from dementia, a condition that puts them at greater risk of death when given antipsychotic medications.

The drugs, also known as “‘psychotropics,’’ were developed to treat people with severe mental illnesses such as schizophrenia, not dementia, which is the progressive loss of memory or other intellectual function than can result from aging or Alzheimer’s disease.

Twice in the past five years, federal regulators have issued nationwide alerts about troubling and sometimes fatal side effects when antipsychotics are taken by people with dementia, including increased confusion, sedation, and weight gain.

Scott Plumb, senior vice president of the Massachusetts Senior Care Association, the trade group representing the state’s 440 nursing homes, said Massachusetts’ consistent ranking as one of the heaviest users of psychotropic drugs indicates much more training is needed in nursing homes.

“We recognize the number is too high,’’ Plumb said, “and we are working to try to bring it down.’’

As the nation ages - up to 14 million baby boomers are expected to develop Alzheimer’s disease or a similar dementia - the drugging of such vulnerable patients takes on increasing urgency. While there has been much focus on the increasing use of antipsychotic drugs among children - highlighted by the recent overdose death of 4-year-old Rebecca Riley - much less attention has been paid to the similar problem among seniors.

“Way too many patients in nursing homes are treated with antipsychotics purely to sedate them or to control behaviors that are difficult for the staff,’’ said Robert A. Stern, an Alzheimer’s specialist and brain researcher at Boston University School of Medicine.

“To the defense of nursing homes and nursing home staff,’’ Stern said, “they are indeed understaffed, they are indeed under-trained, and it takes an awful lot of well-trained people to manage the difficult behaviors that can be exhibited by people with dementia.’’

While there is no barometer for what is considered an appropriate amount of antipsychotic use in nursing homes - and there is no law governing the matter - specialists in caring for the elderly note that the use of antipsychotics is much lower in some homes than others, and in some states than others.

They also point to the federal government’s recent legal action against the largest provider of drugs to nursing homes in the United States. The company, Omnicare, agreed in November to pay $98 million to settle charges that it took kickbacks from Johnson & Johnson to recommend the drug maker’s products, including the antipsychotic Risperdal. The government said Omnicare persuaded physicians to prescribe the medication to dementia patients with behavioral problems. A government suit against J&J is pending.

Specialists say antipsychotics can improve the quality of life for some dementia patients who suffer from extreme agitation and sleeplessness, common symptoms of Alzheimer’s. But too often nursing homes don’t regularly reevaluate patients’ medications to determine whether the antipsychotics are, in fact, effective and whether the dose can be lowered or eliminated, said psychologist Paul Raia, vice president of clinical services for the Massachusetts and New Hampshire Alzheimer’s Association.

Raia helps train nursing home staff in behavior management techniques that can ease agitation and the need for the drugs - skills and training that, specialists say, are often lacking in nursing homes in Massachusetts and across the country. In these homes, he said, as many as 80 percent of the residents are on antipsychotic drugs.

“And then I walk into a good place, one with training, and see 2 or 3 percent on these medications,’’ he said.

A nursing home’s track record for antipsychotic use often is a good predictor for future patients, according to new research from the University of Massachusetts Medical School. The scientists analyzed data from 1,257 nursing homes nationwide and found that patients newly admitted to facilities with some of the highest rates for prescribing antipsychotics are 37 percent more likely to receive the drugs than patients entering homes with the lowest prescribing rates.

Nicki Solomon of Norwood has seen those highs and lows. In 2007, she placed her mother, Corinne, in a nursing home. Although the retired surgical nurse suffered from dementia, she was still able to feed herself and converse clearly, but she had lost her short-term memory, was sometimes agitated and anxious, and would wander off.

Solomon said the nursing home, High Gate Manor in Dedham, asked her permission to prescribe her mother an antipsychotic but didn’t explain the potential side effects. Within weeks, Solomon said, her mother was transformed into someone she didn’t know.

“My mother was out of it all the time. She was asleep and noncommunicative,’’ Solomon said. “She was smothered.’’

She had been given Seroquel, Solomon said, one of the drugs that federal regulators months later would specifically warn against for dementia patients.

High Gate, citing patient confidentiality laws, declined to comment on Solomon’s care.

In June 2008, Solomon transferred her mother to a Needham nursing home that specializes in using alternatives to medication in caring for dementia patients. Her mother rebounded, she said, living another 15 months before her death last November.

Alice Bonner, the state’s top nursing home regulator as director of the Bureau of Health Care Safety and Quality, said “culture change,’’ including a growing consumer movement that focuses on more closely involving families and patients in care decisions, can lower the use of psychotropic drugs.

“We can do better, and use fewer drugs, and do more with behavioral interventions by changing the way we deliver care in nursing homes,’’ she said. Her agency is developing a brochure for nursing homes to give new residents and their families, encouraging them to ask y about the medications prescribed.

For Sharlene Hemp, a North Andover resident who says her father died from side effects of psychotropic drugs just 34 days after entering a nursing home, the answer is legislation. Her father had Alzheimer’s, but she said the family was never told about the medications nor of the potential lethal side effects, until after his death in 2001.

Hemp persuaded her state senator, Steven A. Baddour, to file legislation that would require all Massachusetts nursing homes and their prescribing physicians to obtain written permission from a patient’s health care proxy, which is often a family member, and a court appointed guardian before using antipsychotic medications. A public hearing was held on the bill in January, and it remains in committee.

“When you put a loved one in a nursing home, you are putting your trust in the nursing home and the doctor,’’ Hemp said. “But you don’t know when they go in that they are given all these drugs, and especially dementia patients, because they can’t tell you what they are given.’’

Kay Lazar can be reached at klazar@globe.com.
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