Most nursing homes are prohibited from using “chemical restraints”. But some can bend the rules.

Antipsychotics are dangerous for patients with dementia, almost doubling their risk of death, but a New York Times The investigation found that some understaffed nursing homes may use the drugs to subdue patients and then circumvent disclosure requirements by falsely diagnosing patients with schizophrenia.

The long controversy around antipsychotics in nursing homes

In 1987, a law signed by President Ronald Reagan prohibited the use of drugs in nursing homes that served the interests of the staff rather than that of the patient, except “to ensure the physical safety of the resident or other residents.”

However, antipsychotic drugs like Seroquel, Zyprexa, and Abilify were used frequently in the early 2000s on patients with dementia, despite the fact that these drugs make older patients more drowsy, more likely to fall, and almost double the risk. deaths of patients with dementia, Times reports.

Caring for dementia patients is a difficult task, even more so for understaffed nursing homes, which is common in the United States and intensified during the pandemic. Nursing home employment has fallen by more than 200,000 since the start of last year, hitting a 27-year low, the Times reports.

Research has shown that the more understaffed a nursing home, the more antipsychotic drugs it uses, suggesting that some nursing homes use the drugs “to restrain patients and avoid having to hire additional staff.” Times reports.

A suspicious spike in schizophrenia diagnoses

In 2012, CMS began requiring nursing homes to report data on antipsychotic drug use, which then became part of each nursing home’s ‘quality of resident care’ score which contributes to the ranking by CMS stars of an establishment.

However, nursing homes were not required to report antipsychotic prescriptions for patients with one of the following three conditions: schizophrenia, Tourette’s syndrome and Huntington’s disease, Times reports.

Since then, according to Medicare data, the share of nursing home residents diagnosed with schizophrenia has increased by 70%. And today, one in nine nursing home residents have been diagnosed with illness, despite the illness affecting just one in 150 people in the general population, the Times reports.

Schizophrenia is also usually diagnosed before the age of 40, the Times reports. “People don’t just wake up with schizophrenia when they’re old,” said Michael Wasserman, geriatrician and former nursing home executive. “It’s used to bend the rules.”

In May, a report from a federal watchdog agency found that nearly a third of long-term nursing home residents diagnosed with schizophrenia in 2018 had no Medicare treatment records for the disease.

And another report from May of HHSThe Inspector General found 52 nursing homes where at least 20% of residents had an unsubstantiated diagnosis, more than half of which had received at least a four-star rating from CMS.

Since Medicare does not require nursing homes to report antipsychotic prescriptions for patients with schizophrenia, data released online by Medicare shows an undercount of patients using the drugs, the Times noted.

The Medicare website says less than 15% of nursing home residents take antipsychotic drugs, but that figure excludes patients diagnosed with schizophrenia. The data obtained by the Times from another Medicare site and an open case request from a patient advocacy group that included these patients found that at least 21% of nursing home residents were taking antipsychotic drugs.

What happens to facilities that abuse diagnoses of schizophrenia?

Institutions are rarely sanctioned for these diagnoses either, Times find. An analysis of government inspection reports by the Times found 5,600 cases of inspectors claiming that nursing homes misused antipsychotic drugs. In response, nursing home officials said the drugs were used for a variety of reasons, from “maintaining health” to dealing with patients who “whined” or “asked for help,” the doctor said. Times find.

In total, in over 99% of cases, the inspector concluded that the violations represented only “potential” rather than “real” harm to patients, meaning that the findings were not likely to be corrected. affect the star rating of establishments, Times find.

In response to the TimesCMS spokeswoman Catherine Howden said the agency was “concerned about the practice as a way to circumvent the protections offered by these regulations.”

“It is unacceptable for a facility to inappropriately categorize a resident’s diagnosis to improve its performance measures,” Howden said. “We will continue to identify facilities that do and hold them accountable.”

Meanwhile, David Gifford, CMO of American Healthcare Association, who represents for-profit nursing homes, said: “If doctors incorrectly diagnose people with serious mental health issues in order to continue with antipsychotic therapy, they should be reported and investigated. investigation.”

Representatives from the nursing home industry have also reported a decline in the reported use of antipsychotic drugs since the 2012 requirement came into effect, although the Times reports that the reported decline is partly offset by the increase in schizophrenia diagnoses and has been reversed since the start of the Covid-19 pandemic.

Nursing homes may turn to other drugs to keep patients under control

In response to the federal government’s efforts to limit the use of antipsychotic drugs in nursing homes, some facilities have turned to Depakote, a drug used to treat epilepsy and bipolar disorder, which can make patients drowsy and increase. their risk of falling, Times reports.

“The prescription is much higher than one would expect based on the actual amount of epilepsy in the population,” said Donovan Maust, geriatric psychiatrist at the University of Michigan.

Since the government began requiring reporting of the use of antipsychotic drugs, prescriptions for Depakote and other similar drugs have increased. Between 2015 and 2018, the use of these antiepileptic drugs increased by 15% among nursing home residents with dementia, according to an analysis prepared by researchers at the University of Michigan for the Times.

At the same time, prescriptions for antipsychotics fell 16%.

According to a federal whistleblower lawsuit against Abbott Laboratories, the former maker of Depakote, representatives for the drug maker told nursing homes that Depakote was a way around the 1987 law banning the use of drugs as “chemical restraints.”

The lawsuit claimed that Abbott officials said the drug would “fly under the radar screen” of government regulations, the Times reports.

The lawsuit was settled in 2012 with Abbott agreeing to pay $ 1.5 billion to resolve the allegations against him.

According to Anthony Chicotel, the best lawyer in California advocates for nursing home reform, about half of the complaints they receive are from nursing home residents who have been inappropriately drugged with Depakote.

Chicotel said that one of the attractions of Depakote is that it comes in a “sprinkled” form, which makes it easy to slip into a patient’s food.

“It’s a drug that is tailor-made to chemically overpower residents without anyone knowing about it,” he said.

Currently, the government does not require nursing homes to report their use of Depakote or similar drugs, the Times reports.

“It’s like an arrow pointing to this class of drugs, like ‘Use us, use us!’,” Maust said. “Nobody keeps track of this.” (Thomas et al., New York Times, 9/14)

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