Esaseyer to Drug Video ‘Easier to drug people up’: US nursing homes misuse medication
‘Easier to drug people up’: US nursing homes misuse medication
(Sacramento) – Nursing homes across the
routinely give antipsychotic drugs to residents with dementia to control their behavior, despite rules against the misuse of drugs as “chemical restraints,” Human Rights Watch said in a report and video released today. This abusive practice remains widespread, even though the use of antipsychotic drugs on older people with dementia is associated
The 157-page report, “‘They Want Docile’: How Nursing Homes in the United States Overmedicate People with Dementia,” estimates that every week in US nursing facilities, more than 179,000 people, mostly older and living with dementia, are given antipsychotic drugs without an appropriate diagnosis. Facilities administer these drugs in many cases without obtaining informed consent from residents or their families.
“People with dementia are often sedated to make life easier for overworked nursing home staff, and the government does little to protect vulnerable residents from such abuse,” said Hannah Flamm, NYU School of Law fellow at Human Rights Watch. “All too often, staff justify using antipsychotic drugs on people with dementia because they interpret urgent expressions of pain or distress as disruptive behavior that needs to be suppressed.”
Using antipsychotic medications as a “chemical restraint” – for the convenience of staff or to discipline residents – violates federal regulations and can amount to cruel, inhuman, or degrading treatment under international human rights law. Yet even when nursing homes are found to have broken these rules, they are rarely punished.
How Nursing Homes in the United States Overmedicate People with Dementia
The report is based on visits by Human Rights Watch researchers to more than 100 nursing facilities in six states and more than 300 interviews with people living in facilities, their families, staff, long-term care and disability experts, government officials, and advocates.
About 1.1 million people aged 65 and over lived in around 15,600 nursing facilities across the US in 2017. Medicaid, the main US public health insurance program for people with low incomes, which is jointly administered by the federal government and the states, is the primary payer for this form of long-term care.
Antipsychotic drugs were developed to treat psychiatric conditions like schizophrenia. The Food and Drug Administration (FDA) requires manufacturers to label them with the strongest “black box” warning about the risks they pose to people with dementia. The FDA has never approved antipsychotic drugs as safe and effective for treatment of dementia symptoms.
Federal regulations bar using the drugs without adequate indication for use or appropriate monitoring, and the Obama administration planned to strengthen regulations around their discretionary, “as needed” use. However, in November 2017, the Centers for Medicare & Medicaid Services (CMS) announced a moratorium on this and other strengthened regulations.
Congress and several
that the overuse of antipsychotic medications is a major problem. While the percentage of residents receiving them has declined in recent years, their use remains widespread. Around
of people in US nursing homes are given these drugs
, according to government data. In
, more than 30 percent of residents are given the drugs in this way. As the director of nursing at one facility in Kansas told Human Rights Watch, “antipsychotics are a go-to thing.”
Nursing home residents and their families described the awful consequences, including sedation, fear, and frustration. A 62-year-old woman who said she was given Seroquel without her knowledge or consent at a nursing facility in Texas said: “[It] knocks you out. It’s a powerful, powerful drug. I sleep all the time. I have to ask people what the day is.” The daughter of a 75-year-old woman recalled that when a nursing facility in Kansas put her mother on an antipsychotic drug she “would just sit there like this. No personality. Just a zombie.”
The use of antipsychotic drugs without permission from the resident or their proxy is common, Human Rights Watch found. Federal regulations require nursing facilities to inform residents of treatment options and to give them the right to refuse treatment. Some state laws require informed consent for these medications. Yet staff at many facilities openly admitted they do not even try to follow these rules.
A former nursing home administrator in Kansas said: “The facility usually gets informed consent like this: they call you up [the healthcare proxy]. They say, ‘X, Y, and Z is happening with your mom. This is going to help her.’ Black box warning? ‘It’s best just not to read that.’”
The US government is failing to hold nursing homes to account for mistreating residents through the inappropriate use of antipsychotic drugs, Human Rights Watch said, despite strong regulations on paper.
The Nursing Home Reform Act of 1987 established strong legal protections of the rights of people in nursing homes; in practice Human Rights Watch found that the regulations pertaining to antipsychotic drugs are weakly enforced. Data from CMS show that government inspectors issued 7,039 citations to nursing facilities for violations related to antipsychotic drugs between 2014 and mid-2017. Since 97 percent of these citations were deemed to have caused “no actual harm,” they did not carry mandatory financial penalties – the primary means of enforcing the rules. Unsurprisingly, Human Rights Watch also found that citations did not change the use of antipsychotic drugs in those homes.
Some nursing homes have significantly reduced their use of antipsychotic drugs, Human Rights Watch found, by carefully reviewing residents’ needs. In retrospect, staff at these facilities concluded that the drugs had been used far too widely. One director of nursing in Kansas said: “It used to be like a death prison here…. Half our residents were on antipsychotics.”
CMS and its state counterparts should strengthen their enforcement of federal regulations regarding antipsychotic drugs. Residents and their families should be told they have the right to be informed of their treatment alternatives and their right to refuse. The government should ensure nursing homes employ enough staff to provide adequate care.
“The US government pays nursing homes tens of billions of dollars per year to provide safe and appropriate care to residents,” Flamm said. “Officials have a duty to ensure that these often vulnerable people are protected rather than abused.”
By DAVID CRARY AP National Writer
U.S. nursing homes have significantly reduced the use of powerful antipsychotic drugs among their elderly residents, responding to pressure from many directions. Yet advocacy groups insist that overmedication remains a major problem, and want the pressure to intensify.
According to the latest data from the federal Centers for Medicare & Medicaid Services, known as CMS, the percentage of long-term nursing home residents being given antipsychotic drugs dropped from about 24 percent in late 2011 to under 16 percent last year. Decreases were reported in all 50 states, with the biggest in Tennessee, California and Arkansas.
Dr. Jerry Gurwitz, chief of geriatric medicine at the University of Massachusetts Medical School, depicts the overall decrease as “one of the most dramatic changes I’ve seen in my career.” He wonders, however, if some nursing homes might be finding other medications that sedate their patients into passivity without drawing the same level of scrutiny as antipsychotics.
Advocacy groups — including the Washington-based Center for Medicare Advocacy and AARP Foundation Litigation — say even the lower rate of antipsychotic usage is excessive, given federal warnings that elderly people with dementia face a higher risk of death when treated with such drugs.
“Given the dire consequences, it should be zero,” said attorney Kelly Bagby of the AARP foundation, which has engaged in several court cases challenging nursing home medication practices. Bagby contends that the drugs are frequently used for their sedative effect, not because they have any benefit to the recipients.
The advocacy groups’ long-running campaign was reinforced Monday with the release of a detailed report by Human Rights Watch urging federal and state authorities to take tougher measures against improper use of antipsychotic drugs.
“On paper, nursing home residents have strong legal protections of their rights, but in practice, enforcement is often lacking,” said the report, based on interviews with more than 300 people and visits to 109 nursing homes in six states.
Ten years ago, according to the Department of Health and Human Services, roughly 270,000 nursing home residents suffering from dementia were receiving antipsychotic drugs even though such medications are not approved to treat that condition. The powerful class of drugs is intended, instead, to treat serious mental illnesses such as schizophrenia and bipolar disorder.
Analyzing the latest government data, Human Rights Watch estimates there are now about 179,000 people in nursing homes who get antipsychotics every week without having a diagnosis for which the drugs are approved.
“Antipsychotic drugs alter consciousness and can adversely affect an individual’s ability to interact with others,” the new report says. “They can also make it easier for understaffed facilities, with direct care workers inadequately trained in dementia care, to manage the people who live there.”
The report also says that nursing homes, in violation of government regulations, often administer antipsychotic drugs without obtaining consent from residents or the relatives who represent them.
Hannah Flamm, the report’s lead author, said the recent data showing a decline in antipsychotic usage demonstrated how extensive the overmedication problem had been. In an interview, she said the lower numbers don’t impress her.
“Would you want to go into nursing home if there’s a one in six chance you’d be given a drug that robs you of your ability to communicate?” she asked. “It’s hard for me to applaud the reduction when it’s inexcusable to ever misuse these drugs.”
The American Health Care Association, which represents more than 13,000 U.S. nursing homes, was active in the national partnership formed by CMS in 2012 that worked to reduce unnecessary use of antipsychotics.
The association’s senior vice president for quality and regulatory affairs, Dr. David Gifford, said a majority of the organization’s members reduced usage by more than 30 percent, while some others failed to fully embrace the initiative.
The biggest challenge, Gifford said, is to change a mind-set among some nursing home staff and some residents’ families that behavior arising from dementia is “abnormal” and warrants the use of antipsychotics.
“There’s been dramatic improvement, but there’s room for more improvement,” he said.
Advocacy groups contend that federal enforcement of medication regulations has been too lax and will only grow more lenient as President Donald Trump’s administration pursues an agenda of deregulation.
“They’re helping the industry, not the patients,” said attorney Toby Edelman of the Center for Medicare Advocacy:
Gifford disagreed that enforcement was inadequate.
“The advocates want it to move faster, and I don’t blame them for wanting that,” he said. “But the approach being used is very successful.”
Gifford also disagreed with the suggestion that nursing homes used the antipsychotics as a sedative to compensate for staffing shortages.
“If someone is sedated, you need more staff,” Gifford said. “The amount of staff is related to how much people can do for themselves.”
Laurel Cline, a California woman whose 88-year-old mother has dementia, described a different scenario. She said her mother, during stays at three different nursing homes in recent years, was sometimes left neglected for hours at a time in her wheelchair after being given antipsychotics.
In each facility, Cline said, it was a struggle for her to convince management that those dosages should be stopped. On a few occasions, she said, staff members said her mother would have to leave the home if she were taken off antipsychotics.
“Instead of seeing what’s wrong with her, they just want to drug her up,” said Cline.