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

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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

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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
trial;

 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

Daniel Carlat on Antipsychotic Medications for Agitation in Patients with Dementia

Lately, it seems like all the press about psychiatry in The New York Times is bad. We don't talk to our patients, we over-medicate them all from the children to the elderly, we all get bribes from drug companies. It's not that I don't think that these things don't happen, it's just that I don't like the sensational tones, and the one-sided nature of the presentation of psychiatrists as bad, the generalizations that it's "everyone," and the use of information taken out of context to make our practitioners look bad.

In a May 9th article Gardiner Harris writes:

More than half of the antipsychotics paid for by the federal Medicare program in the first half of 2007 were “erroneous,” the audit found, costing the program $116 million for those six months.

“Government, taxpayers, nursing home residents as well as their families and caregivers should be outraged and seek solutions,” Daniel R. Levinson, inspector general of the Department of Health and Human Services, wrote in announcing the audit results.

Mr. Levinson apparently feels the government should collect information on diagnoses so correct prescribing can be assessed.

On CNN today, Danny Carlat writes his own response in "In Defense of Antipsychotic Drugs for Dementia."

The story highlights include:

STORY HIGHLIGHTS

• Daniel Carlat: Report implies evil doctors are giving deadly drugs to nursing home patients
• But antipsychotics are most effective drug for calming agitation in dementia, he writes
• Carlat: No drugs are FDA-approved for this agitation, a terrible condition

Carlat writes:

But in this particular case, the Office of the Inspector General has it wrong, and Levinson's statements on behalf of Health and Human Services reflect an astonishingly poor understanding of the workings of medical care in general and psychiatric care in particular.

The unfortunate fact is that no medications are FDA-approved for the agitation of dementia, and yet the condition is common.

Although it's true that a prescription for antipsychotics to treat agitation in dementia is "off-label," this hardly means they are ineffective or that Medicare claims for these drugs are "erroneous." In fact, large placebo-controlled trials have shown that antipsychotics are the most effective medications for the agitation that often bedevils patients with dementia.

When these drugs are successful, they soothe the inner turmoil that makes life intolerable for these patients, improving their quality of life dramatically.

More On Everyone's Favorite Medication: Xanax

First, check out Roy's post below from earlier today; he tells us how to cure alcoholism! Click Here.
[I do nothing of the kind, don't listen to her.]

So the New York Times has a health blog, and if you ask me, today it's trying to be Shrink Rap. In today's Post, For Some Bereaved, Pain Pills Without End,
the unnamed author talks about the ease with which physicians ( primary care docs) prescribe benzodiazepines for acute grief, the ease with which they refill these scripts-- often for years at a time--, the ease with which these patients become addicted and suffer from side effects:

Powerful benzodiazepines such as Xanax, Valium and Ativan are widely overused in older patients, many experts fear, leading to serious health worries, including sleep troubles, cognitive difficulties, car crashes and falls. Yet doctors in the survey seemed willing to offer unlimited amounts of these addictive drugs to help patients cope with death.

The study is small-- it consists of 33 primary care docs in Philadelphia, and interviews with 50 older patients who've taken benzodiazepines for years: 20% said they began taking benzodiazepines during a period of grieving. Want details? Read the original article HERE.

As always, the reader comments are as enlightening as the blog post itself (ah, that's true here at Shrink Rap as well).

Interesting stuff, but I guess I think the sample here is so small as to be useless. Half the docs said they'd prescribed benzos for grief (so at least 16.5 primary care docs) and 10 patients started chronic benzodiapine use after a death. I'm not surprised, I'm not commenting on anyone's practice, I guess I just don't like the tone of the blog post which somehow paints the docs as ignorant, perhaps lazy, may be even negligent or sinister.

Finally, please note that I stole my "grief" graphic from a Red Sox blog: http://redsoxdiary.blogspot.com/

Conscientious Nuns Less Likely to Get Alzheimer's Disease

First I got an email about this from Medscape. Then I saw it in the Wall Street Journal's Health Blog. Then I clicked through to the abstract from the Archives of General Psychiatry.


So there's this prospective study of Catholic clergy--priest, nuns, and brother-- called The Religious Orders Study at Rush University, where the participants have yearly physical and psychological exams and agree to donate their brains for autopsy at the appropriate time. Wow. The Religious Orders Study has been going since 1993 and is funded by the National Institute on Aging.

Okay, so Jacob Goldstein at the WSJ blog tells us:

A high conscientiousness score — which the authors describe as reflecting a “tendency to control impulses and be goal directed” — was associated with an 89% reduction in the risk of disease compared with a low score, even after accounting for age, sex and education.

By 'sex' I think he means gender.

At any rate, this study made me think of my dear friend ClinkShrink, pictured above, who a) is often mistaken for a nun and b) is very conscientious.

I'm hoping this bodes well for her brain. If not, I'll still be her friend.

I'm Not Old

I was eating lunch with a friend the other day. She was talking about her sick friend, her husband's upcoming big birthday, her mid-life crisis of sorts.

"I'm not looking forward to this next phase of life," she said.

"Huh?"
"Getting older. What's to come."

Age, I've decided after years of watching people, is a matter mostly of luck and partly of mindset. Mostly of luck. I've seen people who are old by 40. I've seen people in their 70's, and sometimes even 80's, who are still full of life. I recently treated a man in his early 90's who still had stuff going on.

"I'm not getting old," I said. I feel fine, why would I spend my time thinking about impending disability.

My friend is a runner, she's tall, slim, beautiful, and has two sons in elementary school. She looked at me shocked.

"You're my age. You're in denial."

Perhaps I am. My children, especially the younger one, tell me I'm old at every turn. Actually, I'm a bit younger than most of their friends' parents. I tell them so, it bounces off and lands with a thud.

Back in the day, I think. I can remember, and I'll leave you with a list:

Going to the library to do research out of books.

Finding those books after looking them up in the big card catalogue which took up half the room.

Finding journal references in The Readers' Guide To Periodic Literature (or something like that) and reading the reels on microfilm.

Answering the phone, attached to the wall.

Not knowing who was calling until you actually answered.

Dialing. Really, dialing.

Staying home to wait for a call.

Using pay phones, routinely.

I was in med school the first time I saw a cell phone. It looked like a vacuum cleaner. Well, not really.

Television in black and white, though the neighbors had color.

Getting up to change the channel.

TV Kids who said "Golly Gee" and no one cursed.

Saying to my big brother: "I turned it on, you turn it off," when no one wanted to get up.

Saying to my big brother: "You turned it on, you turn it off," when no one wanted to get up.

Television shows that had to be watched when they aired, not on video tapes or TiVo.

Movies on big screens only, as double features.

Radio: shaped like an orange ball that played AM only. Taking it to the beach.

Records that came as 45's and 33's and got scratches.

Oddly enough, all the recording artists were the same then as now.

Riding in cars without buckling the seat belts. (I don't remember ever being in a car that actually didn't have seat belts).

Cars where you stuck the key into the lock to open the door.

Cars with roll down windows.

Typewriters. I remember typewriters. I even remember manual Smith Coronas. I remember carbon paper and erasable paper. (Oh my God, I AM old.)

Keypunch and all those keypunch cards. I remember COBAL.

Huge computers that filled cold rooms. Something called DEC-10.

Volkswriter, and then WordPerfect.

Elavil and haldol and there was no Prozac, no atypical anti-psychotics.

Patients stayed in psychiatric units for weeks to months, and even years.

I remember psychiatric units with Adirondack chairs on the lawns and patients went home on overnight passes.

Psychiatric residents who routinely had personal analyses (this may have been a New York thing).

I remember classrooms filled with wild little boys who didn't take stimulants.

I remember a time when I'd never met a child with autism. Learning about autism in college, a very rare condition.

I remember Tab and the world before Diet Coke. Cheerios were unflavored and the only bread was white bread. Scooter pies, Pop tarts and plastic Twinkies tasted good, but Cap'n Crunch ruled. Ronald McDonald toured and lines ran around the block.

So maybe I am old. Someone, please hand me my cane.

Methuselah's Genes

Two interesting new research pieces came out this past week or so on aging and dementia.

First, this piece about a gene which is found more often in folks who live 100 years, suggesting that people with the val-val variant of the CETP gene (cholesteryl ester transfer protein) may have a better shot at living a longer life. Centenarians with this genetic variant were also five times less likely to have dementia. The gene, found on Chromosome 16 (OMIM), produces a protein involved in lipid metabolism which results in larger, less sticky, cholesterol particles. The article came out in today's Neurology.

I looked in PubMed for similar articles from this author (Barzilai) and found this April 2006 article in PLoS Biology looking at several longevity-related genes in this same population. This article describes two genes which are more prevelant in really old people: the val/val (also known as I405V) variant of CETP and the -641C variant of the APOC3 gene (another one that deals with lipids).

Here's what's really cool. This guy has gathered this big group of centenarians and is doing genome-wide scans to determine which genes may be associated with longer (and healthier) lives. This work comes out of Albert Einstein's Institute for Aging Research.

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The second item is the NEJM article, from Gary Small at the UCLA Center on Aging, which showed that a molecule (FDDNP) binds to the amyloid plaques and tau protein tangles which are characteristic for Alzheimer's disease. After an injection of this experimental tracer chemical, a PET scan can then show where this stuff is in the brain. If there's enough of it, and in the right places, chances are good that you have (or are developing) Alzheimer's dementia.

This is just a research tool, at the moment. Neither this imaging tool, nor the above genetic tests, can be used clinically in the assessment of dementia risk or diagnosis. Maybe one day.

technorati tags:aging, longevity, brain, dementia, Alzheimer's, genes, FDDNP, APOC3, CETP, PET, UCLA, Einstein, psychiatry

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