Recent reports in medical literature and even the mainstream media have higlighted the problem of the overuse of antipsychotic medications in nursing homes. The federal government reports that some progress has been made in reducing this drug abuse, but national goals still have not been met. Just how bad is the problem?
According to the Centers for Medicare and Medicaid Services (CMS), in 2010, more than 17% of nursing home residents received daily doses of antipsychotic drugs in excess of recommended levels. In addition, antipsychotics are used off-label in patients who have dementia without psychotic features -- 40% of patients with dementia symptoms received antipsychotics in 2010, and many of these individuals had not been diagnosed as psychotic. "Because of the powerful sedative effects of antipsychotics such as aripiprazole [marketed by Bristol-Myers Squibb and Otsuka as Abilify in the US] or olanzapine [marketed by Eli Lilly as Zyprexa in the US], such medications sometimes are employed as a chemical restraint for nursing home residents with undesirable behaviors," report Jay Gold, MD, and Jody Roth, RN, from non-profit MetaStar.
In June 2012, CMS launched an initiative to reduce the use of antipsychotics in nursing homes by 15% by the end of calendar year 2012. In late August 2013, CMS reported on its progress: "the national prevalence of antipsychotic use in long-stay nursing home residents has been reduced by 9.1% by the first quarter of 2013, compared to the last quarter of 2011." CMS reports that this translates to 30,000 fewer nursing home residents on antipsychotics in the first quarter of 2013, compared with the projected number based on the 2011 prevalence level.
Although it appears that nursing homes have made progress, 9.1% reduction falls far below the target reduction of 15%. Only 11 individual states have reached the 15% target reduction -- and Pennsylvania is not one of them. The problem is not limited to the United States; a recent study in Sweden found that only 39% of individuals in specialized care units who were taking antipsychotics had prescriptions in line with national guidelines for drug type and dose.
The current state of affairs is in conflict with federal regulations concerning the treatment of the elderly in nursing homes. The Code of Federal Regulations (CFR) regarding nursing facilities states in no uncertain terms, "The facility must ensure that residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record." The CFR additionally states that the facility must ensure that "residents who use antipsychotic drugs receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs."
Antipsychotic drugs are expensive -- generic olanzapine can cost $1 per pill -- and have dramatic side effects. Side effects of Abilify include akathisia, tremors, and extrapyramidal disorder. Side effects of olanzapine include bloating, drooling, tics, and trembling. Elderly people treated with antipsychotics are at an increased risk of death compared to placebo.
It requires no great leap of imagination to envision the types of scenarios that may arise when the Baby Boom generation enters nursing facilities en masse. It seems prudent to work to remediate the problem now, before problematic nursing home prescribing behaviors become intractable.