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Efforts mount to cut improper use of antipsychotics for seniors By Thomas Goldsmith
JewishWorldReview.com | (MCT) A prescription for the wrong medicine, or too much of the right one, can cause dullness, danger or even death for older people. That's the word from a growing group of family members, as well as medical, government and nonprofit groups working on medication issues involving older patients nationally. Many people who have placed older relatives in long-term care tell the same story: a frail but communicative person goes into a facility and within a day or so their normal demeanor has changed so drastically as to be unrecognizable. Experts on aging, as well as government and business leaders, attribute such changes to widespread use of behavior-modifying medications, including strong antipsychotics such as Zypresa. These prescriptions often are written "off-label," or contrary to the use of the drug approved by the Food and Drug Administration, according to reports from the Centers for Medicare and Medicaid. An U.S. Inspector General's report last year found that Medicare claims for improper use of antipsychotic drugs amounted to $116 million in six months. Margaret Toman, of Garner, N.C., saw the effects herself when she placed her mother, in her 90s, in a nursing home. "This person who has been resilient and cheerful all her life, was bawling and crying, asking me for help," Toman said last week.
"They thought she was depressed. What they were giving her was supposed to be an anti-anxiety drug, but it didn't work for her." Toman brought her mother home and saw her recover within two days, as the drug left her system. "She wasn't falling apart because of anything inherent, but because they were drugging her," Toman said. Giving inappropriate drugs to control the behavior of older people may sound like a scenario out of a horror movie. For many of the antipsychotic drugs prescribed contrary to FDA labeling, a leading potential side effect is increased risk of death. But the syndrome is real, drawing the attention of regulators and advocates at all levels. Earlier this month, U.S. Sen. Chuck Grassley, (R-Iowa), along with two Democratic senators, proposed an amendment on the topic to a massive FDA bill. "This amendment responds to alarming reports about the use of antipsychotic drugs with nursing home residents," Grassley said. "It's intended to empower these residents and their loved ones in the decisions about the drugs prescribed for them." The amendment wasn't part of the final bill, which still faces House consideration, but it shows a realization at the federal level that the problem isn't going away. The nursing home industry, faced with a federal mandate to change practices, said all the right things in response to the Center for Medicare and Medicaid's late March directive to reduce the use of antipsychotic drugs by 15 percent by the end of this calendar year. Physicians contend that in some cases the powerful drugs are necessary, but they should be used only as a last alternative. Along with physicians and advocates, federal regulators encourage those who look after older people to use methods other than drugs to accomplish their goals. "Many of these individuals are scared, confused, frustrated and have difficulty communicating verbally, so they use behavior as their form of communication. As care providers, we need to listen," said David Gifford, senior vice president for quality and regulatory affairs at the American Health Care Association, a nursing home group. In the Triangle area of North Carolina, long-time advocates for older people Bill Lamb, Carmelita Karhoff and Bob Konrad are pushing a statewide effort to deal with improper prescriptions for people in long-term care. Lamb, a former state social work administrator and a leader of Friends of Residents in Long Term Care, recently took a position with Consumer Voice, a national nursing-home residents advocacy group. Karhoff, a state nursing home ombudsman, is also a leader of the Local Area Network of Excellence, an umbrella organization bringing together public, private and nonprofit groups to improve care. The group will be holding training session across the state beginning next month to emphasize what's called "person-centered care." That means paying primary attention to the needs of patients, rather than focusing on getting the staff's tasks done. "It avoids the anti-psychotic medications and pushes the value of the staff's getting to know the residents," Karhoff said. An important part of the effort will be training staff to defuse situations with older residents, who can be restless, argumentative and even violent as dementia progresses. Leaders such as Alice Watkins, executive director of Alzheimer's NC, acknowledge the difficult jobs direct care workers have while pushing against improper methods that amount to drugging patients. "Medication is used far too often to control behavior rather than using person-centered training techniques to address the situation," Watkins said. Two groups, Friends of Residents in Long Term Care and Consumer Voice, have put medication issues with older people at the top of their policy agendas for the year. Peggy Kline, now a paralegal in Chapel Hill, followed husband Walt through a devastating decline brought on by his Alzheimer's disease. Most of the darker moments were caused by the degenerative disease, but his experience at a Cary, N.C., nursing home shocked Peggy. She had taken the precaution of insisting that Walt's own doctors approve any medication he was put on, an agreement the nursing home didn't keep. "They followed through with their own doctors," Kline said. "He had a reaction to what they were giving him to calm him down. After six days he had to go into the psychiatry ward." Kline, a retired IBM executive was constantly mobile and could not sit still, Peggy Kline recalled. However, the anti-anxiety medication didn't help. That's often the case with off-label drugs, said Dr. Laura Hanson, professor of geriatric medicine and Co-director of the Palliative Care Program at University of North Carolina Hospitals "From research trials, it is not clear that they are effective," Hanson said. "They do not make patients easier to deal with." When patients do react well, the drugs should be prescribed on the same basis that all care is provided: to carry out the best course of action for the individual patient, based on close observation and communication among the treatment team, the patient and family, Hanson said. "If you have concerns about a medication that's being used for behavior control, ask what's being done for your loved one that's non-pharmacological. "Always realize that you have the option to ask for a second opinion."
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