Sunday, January 29, 2012

Antipsychotic Use for Elderly Nursing Home Residents: OIG Report

There have been some recent reports about the increasing use of atypical antipsychotics on both ends of the age spectrum. The US GAO (Government Accountability Office) issued a report in December finding higher rates of psychotropic use, including antipsychotics, in foster children compared to nonfoster children (3-4 times higher). Recommendations for increased vigilance and monitoring were made.

In May 2011, the US OIG (Office of the Inspector General) issued a report entitled, "Medicare Atypical Antipsychotic Drug Claims for Elderly Nursing Home Residents." This report examined claims from a six-month period in 2007, finding that 14% of nursing home residents had at least one claim for an antipsychotic, amounting to over $300 billion. Eighty-three percent of these claims were for off-label conditions (e.g., agitation, insomnia), and 88% were associated with a dementia diagnosis. Atypical antipsychotics carry a warning about using them in elderly patients with dementia due to an increased risk of heart attack and stroke.

So, there was a hearing in November before the Senate Special Committee on Aging about this issue. The hearing itself can be viewed on their website, as well as links to the testimony provided.

This is an important issue, because as our population ages and develops more dementia, the pressure to manage the resulting behavioral problems with pills rather than with patience, understanding, and adaptation. Medications can have a role, but cannot be the only solution and should not be used excessively. Some quotes follow.

I believe that behavior itself is not a disease. Simply put, behavior is communication. In people whose ability to communicate with words is limited (such as patients with dementia), communication tends to be more nonverbal (i.e. behavioral). Our challenge is to figure out what they are trying to say, and if they are in distress, to identify the underlying causes and precipitants. Many of the behaviors that are commonly observed in patients with dementia and that are often labeled as difficult, challenging, or bad, such as agitation, wandering, yelling, inappropriate urination, and hitting are typically reactive, almost reflexive behaviors that occur in response to a perceived threat or other misunderstanding among patients who by the definition of their underlying illness have an impaired ability to understand. ...
Patients with dementia often have trouble comprehending their environment, resulting in misperceptions that are often perceived as threats. In most instances, the key to behavior management in dementia is environmental modification, especially the human environment, which may be as simple as changing our approach and our response in order to prevent and minimize distress.  The fundamental basis of health care is caring for others. The fundamental basis of caring is love, acceptance, and respect for persons.
~Jonathan M. Evans, MD, MPH, FACP, CMD
Vice President, AMDA−Dedicated to Long Term Care Medicine

Medications are used often as the first intervention because family members, care givers, nurses and doctors in ALL settings lack information or training regarding alternatives.  To merely target this one class of drug as the “problem to be fixed” will have the unintended consequence of increasing the use of other, equally risky medications, such as benzodiazepines, anti‐seizure medications and sedative‐hypnotics, all of which have side effects that include confusion, falls, and risk of death.  Furthermore, if the focus is only on the nursing home, we will create barriers to access for care that patients and families desperately need.  In some states, such as California where consent rules regarding the use of any psychoactive medications in nursing homes are in place, some nursing homes have declined admissions because of a “history of behavior problems requiring psych meds”, creating real challenges for caregivers and often requiring patients to stay for long periods in the acute care hospital. The solution to this challenge is not a short‐term fix, but rather a two‐fold strategy that involves systemic application of non‐pharmacological behavioral interventions as the first line of treatment, with close monitoring for appropriate and limited use of medications when the non‐pharmacological approaches have not worked.
~Cheryl Phillips, M.D., AGSF
Senior VP Advocacy, LeadingAge

Despite the severity and frequency of these symptoms, there is currently no FDA approved therapy used to treat BPSD [behavioral and psychotic symptoms of dementia]. As a result, many types of medications, including atypical antipsychotics, have been used “off-label” in an attempt to mitigate these symptoms. In 2005, the FDA examined this issue and found that the use of atypical antipsychotics in people with dementia over 12 weeks helped to reduce aggression, but was also associated with increased mortality. ...
The Association recommends training and education on psychosocial interventions for all professional caregivers. Specifically, the Alzheimer’s Association believes “in making the decision to utilize antipsychotic therapy the following should be considered:

 Identify and remove triggers for behavioral and psychotic symptoms of dementia: pain,
under/over stimulation, disruption of routine, infection, change in caregiver, etc;

 Initiate non-pharmacologic alternatives as first-line therapy for control of behaviors;

 Assess severity and consequences of BPSD. Less-severe behaviors with limited
consequences of harm to individual or caregiver are appropriate for non-pharmacologic
therapy, not antipsychotic therapy. However, more severe or “high risk” behaviors such
as frightening hallucinations, delusions or hitting may require addition of antipsychotic

 Determine overall risk to self or others of BPSD, and discuss with doctor the risks and
benefits with and without antipsychotics. Some behaviors may be so frequent and
escalating that they result in harm to the person with dementia and caregiver that will in
essence limit the life-expectancy and or quality of life of the person with Alzheimer’s
disease; and

 Accept that this is a short-term intervention that must be regularly re-evaluated with your
health care professional for appropriate time of cessation.”
~Tom Hlavacek
Executive Director, Alzheimer’s Association of Southeast Wisconsin


rob lindeman said...

Bravo, Roy, for highlighting this enormity. It should stop.

wv = nolemake; Newspeak for the process of building grassy mounds and covering them with grass

Anonymous said...

Many of the same arguments against using APs as first line treatment hold true non geriatric populations exhibiting problem behaviors etc. Adapting the environment, communication and all that jazz. Why should that not be first line for everyone? Too expensive? Those pills are not cheap but when measured against the cost of greater levels of staffing and of staff training, the do begin to look like a bargain. That is why we have so many people on APs who could well off of them with the right treatments. There is a limited place for their use. We are so overmedicated and medicating.

Sunny CA said...

I keep hoping that some truly effective treatment will appear that will reverse or prevent dementia, like a stem cell treatment. I feel I am genetically likely to develop dementia because so many relatives before me had it. Having observed what it is like to experience severe dementia, I don't think it matters if antipsychotics cause increased risk of heart attack and stroke. I know for certain that neither my mother nor grandmother wanted to be alive in a state of severe dementia, yet they both ended up that way. Being in a state of dementia is not life worth living. It looks like hell to live through. It is unfortunate that anti-psychotics are so expensive, but in time the price will come down as patents run out. While in general I am against drugging people to control behavior, if any drug can relieve the fear, and anxiety and torment that accompany many cases of dementia, this is one time I would be in favor of the drugs. I wonder if other people who have spent a lot of time with a person with dementia would agree with me.

Anonymous said...

Fascinating article. Dementia is truly more difficult on the caregiver than the patient. I watched my grandmother in her final years, be so far gone from Ahlzheimers, that she was never in the present during the last 9 months of her life.

I agree that it takes a lot of patience to deal with someone that has dementia etc.

Anonymous said...

Imagine an elderly survivor of the Holocaust, now suffering from dementia ,who is living out her days in a locked ward. She believes she is back in the camps, pounds on the door and screams to get out. There are a few options. With typical ratios of patients to caregivers, she is sedated with antipsychotics and stops pounding on the door. Taking another approach, staff levels are much greater and when she begs to be let out, a staff member takes her for a walk outside which reassures her.She may need reassuring on a regular basis. It is so much cheaper to sedate but there truly are other ways for so many people if we cared enough to invest in them.

SteveBMD said...

So that's who's prescribing Symbyax!!

All joking aside, I have to agree with ALL of the above commenters, especially the first Anonymous, who (IMHO) correctly points out that APs are often the go-to agents for problematic behaviors, particularly amongst the very young and the very old.

In fact, one of my very first blog posts was about Miguel Rivera, a Florida doctor who takes a refreshingly non-pharmacological approach to these same patients.

Anonymous said...

Had a look at your link. Thanks. There is a home for Alzheimer's patients that takes this approach. The need for APs is significantly reduced when the environment is adapted to take individual needs into consideration. One of the first things I learned early in my own career was that my red blouse might be perceived by the patient as fire, danger. Or, it might not. In any event, we must try to see things through the patients eyes (perspective) and act accordingly. I don't believe we can always eliminate the use of all medications, but we can make them our last line when all else has failed.
I am also a psychiatric patient who is against forced medication and confinement precisely because I know that there are other things that work. we need t value human life enough to try them and stick with them to see results.

Anonymous said...

Certainly my experience of my father's treatment when he was in the last stages of dementia supports the use of behavioural techniques over anti-psychotics. When he was on the psychiatric ward he was angry despite the anti-psychotic, sedative, and anti-depressant medications - he was also poorly cared for, unkempt, wearing dirty clothes (half of which weren't even his), and eating very little. The psychiatrist was insisting on a high-security institution, but when I prevailed and had him moved to a specialist home for people with dementia that promoted behavioural techniques. Within 24 hours he was clean, hair cut, wearing clean clothes, and eating well. Within a few weeks they'd reduced his medications. He might not have been happy but he certainly was less miserable and angry. Unfortunately he died within a few months, possibly because of the side-effects of the anti-psychotic medications.

Shrink2B said...

I know Dinah asked everyone not to comment on her next post - but I had to say thank you, and I feel for you. I have not nearly the experience that you have, and it took me a mere 7 weeks to feel the same frustration when I tried blogging. Thank you for all your effort. I wish you well.

MM said...

That's interesting. It's harsh to say so, but I can see drugging someone just to reduce the load on the staff/caregiver. I wonder if animals or robots could be taught/programmed to reduce problem behavior instead.

Kimberly said...

I've always just lurked around on here, not letting people know who I am... but now I'm just plain sad.

And I know she did not want any comments to her (Dinah) above thoughts... but I must say maybe I am attached to Shrink Rap and the people on here. =|

Kimberly said...

I just want to add something else to my above post.. I'm the most unlikely person to agree with Three Shinks. But I must say sometimes people need to be told to just SHUT the *beep* up! And I'm just the one to say it, being Borderline in all. =)

This is their space on the web, if you don't agree with something said and can't find it in you to be polite when sharing opinions .. don't let the swinging pixel door hit ya on the way out...

Oh... and btw I don't care what people on here think of me.

.....k. Rant over.

Roy said...

Good thoughts, here. Sunny does make me think about the parallels to medicating someone with Alzheimer's (who may permanently lack the capacity to consent) versus medicating someone with a severe mental illness (who may temporarily lack the capacity to consent).

The next post (Feb 1) makes you think.

And thanks, Shrink2B and Kimberly (especially) for your kind words. I can assure you that Dinah will be back when she's done her walkabout.

Anonymous said...

Shrink 2B:

I think the situation over on your blog was quite different. I don't understand why Dinah was taking people's stories about traumatic experiences that led to their views on forced treatment so personally. It was nothing personally against her, just an explanation for their opinions.
You, on the other hand were quite right to take it personally. People were constantly calling you on your attitude toward your own patients and the attitudes you seemed to be absorbing without question from your superiors at the hospital. People found that truly appalling and yes it was personal. I hope you learned something instead of turning a deaf ear to what people were saying to you, but somehow I doubt it. Maybe we were trying to change the world one shrink at a time with you but oh well. Nobody ever listens to us. It was a real eye-opener for me though to actually hear the behind the scenes attitudes that lead to the mistreatment of patients. I was shocked and appalled.

Anonymous said...

Sure, anytime you want to close your ears to the legitimacy of someone's suffering just label them Axis II. Then their opinion doesn't count anymore. (Or how the psychiatric profession creates a population that is a stigma within a stigma.)

Sunny CA said...

I understand the parallel you are making, but my observation of my mother and grandmother was that they were desperately unhappy in their demented state. Their behavior was not a problem for me or the staff so it was not behavior that needed controlling, but mood that needed elevating.

My grandmother thought that another patient who liked to sit on a chair in the hallway outside her room was my grandfather (who was dead for over 25 years) and that he refused to come in to see her. My mother kept discovering day after day, for the first time, that my father was dead. If any psych meds might have made them happier in their last years I would have been all for that. As it was, though confused, both my mother and grandmother were miserable. Neither was aware of their physical limitations or their age, and often they had trouble putting together a full sentence, but both were in a state of desperation, with crying and moaning and anguish. I would have approved medications to make them less anguished.

I am one who rolled both my mother and grandmother outside in wheelchairs (in different time periods) to enjoy the outdoor walkways, and who brought in photos and magazines to look at with them. I rubbed skin lotion into their dry skin, gave them water or special nutrition drinks provided by the staff and brought a cheery attitude. In the end it felt like it was more for me than for them because if I stepped into the bathroom of my mother's room, she was surprised I was there after a 2 hour visit had already taken place. I can imagine it would be demoralizing for staff to take a patient outside for an hour for a patient that does not remember it 1 minute later. As a society, I don't know that it even makes sense to have staff who spend their time with individual dementia patients once the brain is largely gone because it has no impact from my observation. Antipsychotics I took (Abilify and Zyprexa) took away all my emotions. If they could have done that for my mother and grandmother I would have been happy. Perhaps anti-depressants would be more suitable as a first line treatment, though.

clairesmum said...

A couple of observations from my experiences - sometimes you have to work with the resources you have (it would be great to have enuf funding to make nursing homes truly appropriate for those w/ dementia - but who wants to pay MORE so that Medicare and Medicaid can spend MORE than they already do on dementia care). Antipsychotics (not always cheap) are available and do provide some relief.
ALL DRUGS used in ALL patients have risks and benefits - elderly folks are much more vulnerable (as are pediatric patients).
Sometimes a tiny little bit of an antipsychotic is effective in calming the agitation of dementia when none of the other non medication interventions have worked. Using a low dose to help an elder sleep through the night at home (so caregiver can sleep) helps keep elders at home and out of nursing homes longer (usually a key goal).
Sometimes the medical professionals are so against antipyschotics (or the time and effort involved in using correctly or risk management reasons) that they UNDERUSE them - it's horrible to see someone suffering delusions and hallucations and be refused medication due to concern about side effects. Dementia is a progressive and fatal disease - easing suffering is as important as easing physical pain.