Earlier this year, The American Society of Consultant Pharmacists published a report on the use of neuroleptic drugs in nursing homes. According to this report, 25% of nursing home residents receive neuroleptic drugs.
In general, the Centers for Medicare and Medicaid Services (CMS) consider these prescriptions appropriate only if the recipient is psychotic. (Obviously we could discuss this at length, but let’s set that issue aside for now.)
What CMS considers entirely inappropriate, however, is prescribing these products to residents with dementia as a way of controlling “difficult” behaviors such as wandering, being abusive, or resisting care.
In January 2013, CMS produced a 43-page report on this topic titled: Improving Dementia Care and Reducing Unnecessary Use of Antipsychotic Medications in Nursing Homes.
Here’s a quote:
“High prevalence rates of antipsychotic medication use in nursing home residents have been reported in several studies; Much of the use is in residents with a diagnosis of dementia.
According to CMS’s Quality Measure/Quality Indicator report, between July and September 2010, 39.4% of nursing home residents nationwide who had cognitive impairment and behavioral issues but no diagnosis of psychosis or related conditions received antipsychotic medications.” [Emphasis added]
Antipsychotic, or more accurately, neuroleptic, drugs provide little or no treatment benefit for people with dementia. The risks, however, are considerable, including tardive dyskinesia, akathisia, infections such as pneumonia, and reduced life expectancy.
In their report, the American Society of Consultant Pharmacists wrote:
“It is important to note that the Food and Drug Administration requires a ‘black box’ warning on all antipsychotics about an increased risk of mortality when used in older adults with dementia.”
In May of last year, CMS launched a program designed to reduce this off-label prescribing by a modest 15% by the end of 2012. In fact, for all their efforts, the rate declined by only 8% nationally. [Quoted in No restraint at drug-dosing New York nursing homes in The New York World.]
The problem may be lax enforcement. Toby Edelman, senior policy attorney with the Center for Medicare Advocacy, is quoted as saying:
“The other piece of this is stronger enforcement…If they misuse the drugs and have to pay a $139 fine, what do they care? It’s the cost of doing business.” [Quoted in High Use Of Antipsychotics In Nursing Homes Stirs Concerns, Reforms, by Lisa Chedekel.]
Why are neuroleptics, with all their well-established risks, being used so widely to control “difficult” behavior in nursing homes? And why is CMS unable to put a stop to the practice?
Here’s a quote from Gwen Olsen’s 2009 book Confessions of an Rx Drug Pusher:
“It was the end of the third quarter, and I was behind in my sales quota for Haldol…So, I determined the best way to build my Haldol business would be to campaign for the institutionalized patient. These patients were not only encouraged to take the medication; they were actually given the drug. This completely eliminated the compliance issue.”
“I set about scheduling training in-services in the local nursing homes and mental health and mental retardation (MHMR) facilities. I increased my call frequency on physicians whom I knew to have nursing home relationships and directorship responsibilities.”
Ms. Olsen has been out of the business for several years now, but maybe things haven’t changed that much. The pharmaceutical industry gave $234 million to politicians last year. I guess they wouldn’t be doing that if it didn’t buy them something.