June 04--Many institutionalized dementia patients are known to lash out as part of their condition -- to strike the aides trying to feed or clean them, to yell at other patients, to aggressively resist intrusive but necessary medical care such as IVs and catheters.
They are also known to be heavily medicated to control such behavior, a practice that government officials, nursing home industry leaders and patient care advocates say needs to be curbed.
The federal Centers for Medicare & Medicaid Services, or CMS, and the others announced an initiative last week designed to reduce use of antipsychotic drugs on nursing home patients with dementia by 15 percent by year's end. Too often, they say, the staffs of long-term care facilities have relied on the medications to control behavior of patients with Alzheimer's or a similar disease instead of trying other methods, even though the health of those residents can be damaged.
"It's often related to care activities in which the [patient] becomes frightened, bewildered, apprehensive, very anxious -- they don't know what's happening and may resist care or may actually strike out," said Jules Rosen, chief of geriatric psychiatry at UPMC. "What has happened culturally is the knee-jerk reaction of many staff and many doctors is to prescribe these drugs, that it will calm them down. It serves that purpose for some people, and doesn't for others."
The two leading trade groups representing nursing homes, the American Health Care Association and LeadingAge, endorsed the CMS initiative and said they would work with the government to help steer facilities toward other methods with difficult patients. By July, the federal agency plans to list on its website devoted to nursing home comparisons the statistics describing each facility's use of antipsychotic medications on dementia patients.
"We're seeing a number of facilities steer away from these medications, but it's still way too high," said David Gifford, the AHCA's senior vice president of quality and regulatory affairs. "One of the biggest challenges is many clinicians, physicians, nurses and family members think these medications are necessary and effective, but data suggest otherwise."
A CMS report on the issue found that nearly 40 percent of nursing patients with signs of dementia in 2010 received antipsychotic drugs when they did not have any of the conditions for which the medications were government-approved, such as schizophrenia or bipolar disorder. It also stated more than 17 percent of nursing home residents had daily doses of the drugs exceeding recommended levels.
The new initiative calls upon nursing homes to assign consistent staff that gets to know the patients better and can more reliably understand their needs, considering the difficulty many dementia patients have in expressing themselves. Facilities are also being urged to devote more time to alternative behavioral solutions such as music therapy, exercise and other social activities.
Claire Curry, a legal director for the Legal Aid Justice Center, which advocates for patients, said the nursing homes need to learn "to not reach for a magic pill that's going to tranquilize someone, but use these other tools I'm so happy to see CMS pushing. The drug should always be a very last resort."
Government and medical officials note that while commonly used antipsychotic medications such as risperidone and olanzapine can be beneficial, they have not been proved to have the same value for dementia patients as for their intended use and there can be more harmful side effects for patients with Alzheimer's or similar conditions.
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Agencies demand curbs on drugs for dementia
