Cognitive Issues

Reducing Unnecessary Antipsychotic Drug Use in Nursing Homes

September 16, 2013 | by Law Offices of Ben Yeroushalmi

The Department of Health and Human Services Office of Inspector General (OIG) released a report in 2011 finding that antipsychotic drugs given to elderly residents of nursing homes were not administered in compliance with standards set forth by the Center for Medicare and Medicaid Services (CMS). Such medications, when used properly, can be effective in aiding a patient’s mental and physical well-being. However, unnecessary antipsychotic drug administration is dangerous and not appropriate in the care of the elderly. Unnecessary drug administration practices may include excessive dose administrations, drugs provided in excessive durations, lack of adequate monitoring, or the administration of drugs in the presence of adverse effects which show the dosage should be lowered or discontinued. It has been found that improper or excessive administration of antipsychotic drugs may not only result in death but may lead to unnecessary hospitalization, falls, heart attacks, strokes, and other complications.

Unfortunately, because many elderly nursing home residents currently suffer from dementia, there has been a growing concern that antipsychotic medication has been administered inappropriately to control behavioral problems related to dementia. To combat this issue, CMS launched a National Partnership to Improve Dementia Care in 2012 with the goal of protecting the elderly receiving dementia care in nursing homes and other healthcare settings. Specifically, the partnership sought to protect against unnecessary antipsychotic drug use unless there was a valid, clinical purpose. The partnership also sought to encourage nursing homes and others providing dementia care to consider non-pharmacological alternatives for the elderly.

Polypharmacy Observed in Over Half of Nursing Home Residents with Cognitive Disorders

January 2, 2013 | by Law Offices of Ben Yeroushalmi

A recent study observed polypharmacy in nursing home residents. While previous studies have confirmed the dangers of polypharmacy in the elderly, this study is unique because it specifically focuses on patients with cognitive disorders. Approximately 60% of nursing home residents suffer from some type of cognitive disorder. Patients with cognitive disorders, who are more likely to experience polypharmacy, are also at a heightened risk for suffering the dangerous side effects associated with polypharmacy. Patients with cognitive disorders such as dementia are often prescribed antipsychotic drugs. This leads to a complex type of polypharmacy because antipsychotic drugs can be particularly dangerous when mixed with other types of pharmaceuticals and lead to adverse drug reactions.

In this specific study, polypharmacy was considered in any residents taking five to nine drugs simultaneously. Patients taking over ten drugs at a time were categorized as experiencing excessive polypharmacy. All the patients included in the study suffered from advanced cognitive impairment. Of the 1,449 residents studied, 50.7% were observed with polypharmacy and 16.9% were observed with excessive polypharmacy. Patients in which polypharmacy or excessive polypharmacy were observed had a higher risk of developing heart disease, Parkinson’s, gastrointestinal disease, pain, and dyspnea.

The study makes it clear that polypharmacy should be avoided whenever possible. The use of pharmaceuticals must be minimized especially in patients who suffer from cognitive disorders. In dementia patients, use of antipsychotic drugs is known to trigger symptoms such as delirium and agitation. It important to note that these drugs are not intended to treat dementia. The Food and Drug Administration (FDA) does not approve of such use and warns of the dangers of using antipsychotics for off-label purposes. The Center for Medicare and Medicaid Services (CMS) has also recognized that antipsychotics are used rather excessively and unnecessarily in nursing homes and has initiated a program to reduce such use.
Understaffed nursing homes may use antipsychotic drugs for purposes of convenience to chemically restrain patients, who would otherwise require additional care and attention. While a non-pharmocological approach to treating dementia is always favorable, facilities that engage in neglect and elder abuse often sedate residents with antipsychotics before even attempting to use therapies that do not utilize pharmaceuticals. In addition to increasing the risks of polypharmacy unnecessarily, the use of antipsychotics as restraints violates your loved one’s Patients’ Rights. Non-profit organizations such as the California Advocates for Nursing Home Reform (CANHR) are working to end the abuse of antipsychotic drugs in skilled nursing facilities.

A Report on the Lack of Knowledge in Nursing Homes of the Care and Treatment of Dementia

July 10, 2012 | by Law Offices of Ben Yeroushalmi

A new study published in the Journal of American Medical Directors Association, looks into the care of dementia in nursing homes. The researchers focused the diagnosis and treatment aspects of dementia, finding very low levels of each in nursing homes in the US and across Europe. Knowledge about dementia and how to properly care for those suffering is an important issue in nursing homes, as there is usually a high percentage of dementia patients. This means that nursing home staff must be trained and knowledgeable in how to identify, care for, and properly medicate dementia patients.

In America, patients suffering from diagnosed dementia generally make up from 26 to 48% of nursing home populations. This number is probably even higher as patients with general cognitive impairment are not included. Many residents also go undiagnosed, mainly due to a lack of knowledge about the condition on the part of nursing home staff. This recent study has identified that roughly 1/3 of all dementia go undiagnosed, resulting in them never receiving any treatment or specialized care. Official diagnosis with dementia is important as it shapes how the individual care plan is formed. Dementia patients are more susceptible to falls, so special precautions and observation need to be used to prevent such events. More direct care is needed to care for nursing home residents diagnosed with dementia.

Direct care staff are frequently untrained in the identification and care of common nursing home ailments, including dementia. There are two main medications recommended for dementia: cholinesterase inhibitors (ChEIs) and memantine, an N-methyl-D-aspartate receptor antagonist. These two treatments work especially for dementia due to Alzheimer’s and Parkinson’s. The drug can help lessen behavioral problems and aggressive outbursts, meaning that the patient does not have to be restrained and can maintain a more normal and freer lifestyle. This means that the intensity of direct care necessary is lessened, decreasing the possibility of staff burn-out, which is more common when caring for dementia patients. And yet 26 to 60% of patients remain untreated. And even when they are prescribed, it is not uncommon for their use to be discontinued, commonly due to lack of funding. These medications can be beneficial to the patient, and the nursing home facility, so it is important that staff are well informed about their use and in identifying which patients have dementia and are thus can be helped by their use.

Unfortunately due to understaffing and the lack of training in care facilities, there are not enough qualified nursing staff to adequately monitor and assist these patients and unnecessary physical restraints are used to subdue them. Antipsychotic drugs used excessively can act as chemical restraints and benefit from these medications is usually outweighed by the harmful side effects of the drugs. It is important that medication should be individually tailored to each patient’s health needs and not used recklessly and improperly, as happens when used as a chemical restraint. The use of uncalled for restraints, due to a dearth of trained nursing staff, is against the Patients’ Bill of Rights. Nursing homes are required to employ enough staff to individually care for all of their residents. Understaffing can also result in the preventable spread of common diseases and pressure ulcers.

A New Side Effect of Antidepressant Medications of Which You Need to Be Aware

June 10, 2012 | by Law Offices of Ben Yeroushalmi

Depression is a cognitive disorder that plagues one out of every ten Americans. Osteoporosis a bone disease, is also extremely widespread in the American population. Both are especially common in the elderly, and recently, researchers believe they may have found a link between the two. An article published in the June 2012 issue of the Journal of American Medical Directors explores the question “Do SSRIs Play a Role in Decreasing Bone Mineral Density?” The article reports that a certain type of antidepressant drugs may affect bone density. These drugs are classified as selective serotonin receptor inhibitors (SSRIs) and 62% of all antidepressant drugs fall within this category.

This recently discovered side effect of SSRIs highlights the need for extreme caution when administering antidepressant drugs. These types of drugs are very commonly abused in skilled nursing facilities and sometimes even used as chemical restraints. Before your loved one agrees to begin an antidepressant drug regime, make sure that he or she has exhausted all other alternatives. Leisure and social activities are just two examples of non-pharmacological therapies that improve depressive symptoms. The caregiver’s attitude toward his or her patients also has a profound effect on mental health. It is extremely important that your loved one’s caregiver is emotionally supportive and takes the time to personally interact with him or her on a daily basis. This will help prevent patients from feeling socially isolated and delay depressive symptoms.

The link between SSRIs and decreased bone mineral density, however, does not excuse the skilled nursing facility from any liability. In fact, a staff that is continually trained and educated should be aware of these risks and take them into consideration before administering an antidepressant drug regime to their patients. Each and every nursing home patient is entitled to access to an adequate staff. This legal right encompasses both quality and quantity of the staff available. If your loved one’s skilled nursing facility is lacking in either aspect, he or she may be a victim of nursing home neglect.

Furthermore, the nursing home staff is responsible for ensuring effective communication with any other team members that provide care for the patient. By operating under a team environment and maintaining accurate medical records, an efficient nursing home staff is able to prevent adverse drug reactions and polypharmacy, which can occur when a patient is taking an excessive amount of medications at once. By carefully documenting all treatments that the patient is receiving, physicians can be mindful of these other medications before prescribing additional drugs.

New Amendment to End the Abuse of Antipsychotic Drugs in California Nursing Homes

May 27, 2012 | by Law Offices of Ben Yeroushalmi

Antipsychotic drugs, intended to treat mental illnesses such as schizophrenia, are the most commonly abused class of drugs in Los Angeles nursing homes. Despite warnings from the Food and Drug Administration (FDA) that using antipsychotic drugs to treat dementia patients can be fatal, one in four California nursing home residents receive these drugs before they are given safer and less expensive treatments.

Often, these drugs are used to chemically restrained patients, especially in understaffed facilities that lack the resources to provide proper dementia care to their patients. Rather than sedating dementia patients with antipsychotic drugs, nursing homes should be taking a non-pharmacological approach to the treatment of dementia. Numerous studies have been conducted to test the effectiveness of various dementia treatments and the results have consistently shown that dementia treatments should be behavioral in nature and involve social and leisure activities. In fact, other studies have shown that antipsychotic drugs actually aggravate certain symptoms of dementia, such as agitation, violent behavior, and delirium.

Because the abuse of antipsychotic drugs directly threatens the mental and physical well-being of patients, it has become a major issue of contention in nursing homes today. This week, U.S. Senators Kohl, Grassley, and Blumenthal took an initiative to end the abuse of antipsychotic drugs in skilled nursing facilities. They have proposed an amendment to the FDA’s Safety and Innovation Act S. 3187 that requires nursing homes to inform patients of the risks associated with using antipsychotic drugs and receive consent from the patients or their legal guardians before administering these drugs.

The California Advocates for Nursing Home Reform (CANHR) is working diligently to ensure the passage of this amendment. We encourage you to learn more about CANHR’s Campaign to end the Misuse of Psychotropic Drugs in California Nursing Homes. You can also contact California Senators Barbara Boxer and Dianne Feinstein to urge them to vote for this amendment to the Safety and Innovation Act S. 3187.

Even if you feel that the Safety and Innovation Act does not directly affect you or any of your loved ones, it is still important and beneficial for you to support this initiative because skilled nursing facilities are using Medicare funds to pay for these medications. In 2007, $116 million of taxpayers’ money were used to pay for the off-label use of antipsychotic drugs. This money could have been better spent in other areas desperately lacking in funding, or saved by using cheaper and safer non-pharmacological treatments for dementia.

A New Therapy that Los Angeles Nursing Homes Should Use to Treat Dementia

May 10, 2012 | by Law Offices of Ben Yeroushalmi

Dementia is a degenerative disease that can cause many behavioral and psychological symptoms that make patients difficult to care for. Although medications for these symptoms exist, not many studies have been able to provide conclusive evidence that medications such as acetylcholinesterase inhibitors are actually directly involved in relieving symptoms of dementia. As a result, many studies are now looking at non-pharmacological treatments that involve social interaction, simple physical activities, and other daily activities.

A study published in 2012 tested a treatment known by the acronym “MAKS”: “M” for motor stimulation, “A” for activities of daily living, “K for cognitive stimulation (German word is kognitiv), and “S” for a short introductory phase or a spiritual element (discussing topics such as happiness or singing a song). The results were very positive; the MAKS treatment significantly reduced symptoms of dementia for the 146 residents that participated in the study. Two therapists and one aide conducted the MAKS therapy for 6 months (6 days a week, 2 hours a day). Each 2 hour session started with the introductory phase in which a simple group activity was conducted to make everyone feel included. Then, 30 minutes was allotted to motor exercises, such as bowling, croquet, or balancing a tennis ball on a Frisbee and passing it to one’s neighbor. Another 30 minutes was spent on cognitive tasks, and then the last 40 minutes were spent on an individual activity such as preparing a snack or crafting with wood or paper.

After 6 months, participants in the study were less likely to exhibit challenging behavior such as running away and being aggressive and were generally happier. This improved social behavior, decrease in challenging behavior, and improvement in mood was most evident in residents with mild dementia. This study successfully showed that the MAKS therapy can greatly slow down the progression of dementia at an early stage.

Additionally, the study found that not only did the MAKS treatment work, but it also resulted in more long-term results than drug treatments. The MAKS treatment also had no side effects, as opposed to the side effects of drug treatments. The study implies that due to the overall advantage of the MAKS treatment, it is important that nursing homes treat their patients using similar non-pharmacological treatments whenever possible. The MAKS treatment and non-pharmacological treatments similar to it are much cheaper in price compared to the price of drugs, but call for an adequate amount of staff at hand to conduct group activities and to properly supervise each and every resident. Unfortunately, many nursing homes are understaffed, which is why drug treatments are used in place of other more effective and safe treatments.

A Breakdown of the Different Types of Antipsychotic Drugs: What You Should Know Before Taking Them

March 28, 2012 | by Law Offices of Ben Yeroushalmi

A recent article titled, “Comparative Safety of Antipsychotic Medications in Nursing Home Residents” was published by the Journal of American Geriatrics Society. As reported by the article, an entire third of nursing home patients are prescribed antipsychotics at some point during their residence. Because such a large population of nursing home patients take these drugs, it is important to understand the risks associated with antipsychotic medications. This study breaks down the two types of antipsychotics and compares the risks associated with using each one. Typical antipsychotics, also commonly known as conventional antipsychotics, were developed in the 1950s. A second generation of antipsychotic drugs was later developed, and today these medications are called atypical antipsychotics.

The study concluded that in general, the use of atypical antipsychotics is more dangerous, as it was more often associated with negative side effects. These included an increase in cardiac problems, infections, and hip fractures. However, an exception to this was found with cerebrovascular issues, in which case, atypical antipsychotics appeared to pose less of a risk. We hope that your loved one never finds the use of antipsychotic medications necessary, but if he or she does, it is important to understand risks and side effects, in order to do an educated cost-benefit analysis of taking such drugs.

The study also notes that the effectiveness of antipsychotics in Alzheimer’s patients is outweighed by the risks. Although symptoms for various cognitive diseases may appear to be similar, effective treatments for each one are often very different. Inaccurately diagnosing and treating a cognitive disease can be very dangerous, and even lead to death of a patient. Because there are so many fine details that must be understood and considered prior to beginning an antipsychotic drug regimen, it is important that the nursing home staff is trained and knowledgeable in such matters. As many nursing homes are, unfortunately, extremely understaffed, it is common to find nurses who are unable to properly and accurately diagnose and treat various medical problems. It is important that you are aware of this widespread problem, so that you and your loved one can hopefully avoid its many consequences.

One such consequence is the use of chemical restraints. Because the nurses in understaffed facilities are usually pressed for time, they will often automatically resort to the use of drugs, instead of first assessing the patient and considering other treatments that may be safer and more effective. This is especially important in dementia patients. In 2005, the FDA issued a warning of excess mortalities associated with antipsychotic use in adults with dementia. Since then, many studies have been conducted on the various uses of antipsychotics and their overall effect on quality of life in patients who suffer from dementia. The results have all suggested that behavioral therapies are the most effective treatment for dementia patients. In fact, the use of antipsychotics has actually been proven to worsen symptoms of dementia, such as agitation. It is important that you consider the many alternative methods that exist for treating dementia before resorting to the use of antipsychotic medications.

The study concludes by emphasizing the importance of monitoring a patient’s dosage of medications. Close and careful monitoring can prevent consequences of polypharmacy from occurring. The most efficient way to monitor drug use and antipsychotic treatments is to maintain organized and detailed medical records. Studies have actually proven that improper documentation of antipsychotic drug usage leads to a higher rate of death in skilled nursing facilities.

Daily Activities Can Alleviate Depressive Symptoms in Dementia Patients

March 26, 2012 | by Law Offices of Ben Yeroushalmi

Nursing home residents who suffer from dementia often also suffer from coexisting depression. Depression can cause a greater cognitive decline in dementia patients. However, because the overlapping symptoms of depression and dementia such as atypical presentation, lack of insight, and expression difficulties are often overlooked, nursing home residents who suffer from both depression and dementia do not get adequate treatment for both conditions. In lieu of overmedication, alternative methods can be used to alleviate the symptoms of depression. A study published in the American Association for Geriatric Pediatry offers alternative ways to treat depression. These depressive symptoms can be easily remedied by simple leisure activities done two or three times a week.

The study placed thirty-six residents from nine different nursing homes in Hong Kong in three different activities that they would engage in three times a week: mahjong, tai chi, and handicrafts. Results showed that tai chi alleviated symptoms very slightly, and most likely didn’t provide the expected results because the physical movement was too difficult for most residents due to the lack of normal physical activity prior to the study. Results also showed that mahjong had a short-lived effect; symptoms of depression were alleviated immediately after the activity, but returned to baseline level at the follow-up 3 months later after stopping the activity. This means that if done regularly, mahjong will keep nursing home residents at a healthier state of mind, slowing down the cognitive decline of dementia that is caused by depression.

Unfortunately, activity levels in nursing homes are relatively low. The psychological well-being of residents is rarely a priority, and as a result, residents can suffer from both dementia and depression at the same time, causing great emotional distress and cognitive decline. The mahjong activity conducted in the study can be very easily implemented in nursing homes if nursing homes choose to make the effort to hire staff that is motivated to conduct these activities and rouse interest in the residents to engage in these activities. Most nursing homes are usually understaffed and therefore do not have the adequate resources to conduct such activities to improve the quality of care.

Additionally, the activity of choice does not need to be mahjong. The activity can be anything that rouses interest in the residents and whether the activity is doable given the residents’ health limitations (tai chi was deemed too difficult for the residents in the study). The main point to keep in mind is that whatever activity is chosen, it needs to be done regularly. Even the effects of mahjong were limited after the activity was stopped for three months. All nine of the nursing homes that participated in the study discontinued mahjong as an activity despite the results of the study. The cognitive decline of dementia already progresses rapidly, and it is unfair to not implement such a simple activity into the daily lives of residents to prevent their condition from getting progressively worse. There is simply no excuse for nursing homes to have no meaningful activities whatsoever for their residents to participate in.

Five Steps that Nursing Homes Should Take to Counter Dementia-Related Agitation

March 10, 2012 | by Law Offices of Ben Yeroushalmi

An article in the March 2012 issue of the Journal of American Medical Directors Association titled “Is Your Nursing Home a Battlefield?” address the issue of dementia-related agitation in skilled nursing facilities. The article makes the analogy that nursing homes are often comparable to battlefields when dementia patients experience episodes of agitation and refuse care from nurses. Because this issue creates a negative dynamic between nursing home residents, their families, and the staff, it is extremely important to address the issue and understand the solutions that this article suggests.

The first solution is as simple as the elimination of words with negative, violent connotations. Words like “aggressive” and “assaultive” reinforce the idea that the resident intends to harm the caregiver. In actuality, patients who have episodes of agitation are not being violent; rather, they feel the need to defend themselves due to a lack of understanding as to what the intentions of the caregiver are and what purpose his or her actions serve. As a nurse, especially those who handle dementia patients, it is crucial to provide clearly articulated explanations to residents undergoing any form of care or treatment in the facility.

Secondly, the article emphasizes the importance of educating the facility’s staff. This includes nursing aides, directors of nursing, charge nurses, and even the nursing home’s administrators. In addition to having a staff that provides quality care, the skilled nursing facility needs to be adequately staffed. There is a strong correlation between quality and quantity with regard to staffing in nursing homes. Without an adequate amount of staff, it is nearly impossible to meet the high standard of care that each patient needs and deserves.

Nursing homes have strict guidelines and policies to which all patients and nurses must abide. However, the article recommends that the facility maintain a certain degree of flexibility in implementing their policies and guidelines. This openness to modifying certain policies allows for care plans that are more individualized and receptive to the patient’s specific needs. For example, if a patient tends to resist care early in the morning, perhaps the facility staff should consider a later wake up time.

The article also suggests that nursing home facility’s give nursing aides more significant roles in decision-making. The abilities of nursing aides are often undermined, as it is often assumed that they are merely expected to carry out tasks assigned to them by directors of nursing. However, those who make these assumptions overlook the fact that nursing aides provide the most direct care to patients and interact with them on a daily basis. Therefore, the article recommends that nursing aides be included in care plan meetings. As they are most familiar with patients’ needs and preferences, allowing nursing aides a role in decision-making will result in more effective care plans.

Lastly, the article asserts the importance of treatment for patients who reject care. Often, rejection of care is a sign of pain, delirium, delusions, or depressions. Therefore, patients must be carefully evaluated so that they can receive the proper care, before symptoms become more serious. As with every recommendation that the article has made, training of the facility’s staff is instrumental in this step. Previous studies have shown that nurses often fail to recognize symptoms until it is too late and complications have progressed too far. Recognizing and diagnosing delirium poses and especially difficult challenge for nurses. For this reason, nurses must be trained to be observant and recognize the signs of various health complications that arise in skilled nursing facilities.

In addition to ensuring that the nursing home is adequately staffed, you should also be wary of the use of antipsychotic drugs to chemically restrain residents who suffer from dementia. Other than this being a direct violation of the Patients’ Bill of Rights, it is also extremely dangerous and has been proven to actually aggravate episodes of agitation.

A Recent Study Confirms Adverse Effects of Polypharmacy in Los Angeles Nursing Homes

March 9, 2012 | by Law Offices of Ben Yeroushalmi

While we are fortunate to be living in a modern world that is constantly making advancements in the field of medicine, the side effects of pharmaceuticals can often be dangerous and have implications that must be assessed. The March issue of the Journal of American Medical Directors published an article titled “Exploring Variation in Rates of Polypharmacy Across Long Term Care Homes.” The study on polypharmacy, which the article defines as “the use of multiple, concurrent drug therapies” produced startling results on just how many medications nursing home residents today are taking on average.

If a patient was on nine or more drug regimes at once, the study considered this a practice of polypharmacy and compared the quality of life of these patients to those who were taking fewer medications. The study found that patients subject to polypharmacy were more likely to have comorbidities. This group comprised about 15.5% of nursing home patients taking nine or more drugs simultaneously. Only 2.9% of patients were taking no drugs, and the remaining 81.6% were using anywhere between one and eight drugs at once. The most commonly used drugs include diuretics, proton pump inhibitors, and enzyme inhibitors.

Additionally, the study noted that in general, psychoactive drugs are also one of the most frequently used drugs in nursing homes. Previous studies have established that psychoactive drugs, although intended for treatment of illnesses such as schizophrenia, are often administered to patients who suffer from dementia. Because dementia patients may have episodes of agitation, nursing homes often find it convenient to sedate these residents with psychoactive drugs in order to prevent these episodes from occurring. However, this improper use of pharmaceuticals is an example of a chemical restraint and is in direct violation with the Patients’ Bill of Rights. Furthermore, studies have concluded that the use of psychoactive drugs in dementia patients has reciprocal effects and can actually cause agitation and worsen the overall condition of the patient.

In addition to triggering agitation in dementia patients, drug use can also cause delirium. It is important that you monitor your loved one’s drug intake, as well as the staff that is administering these drugs to him or her. Sometimes, understaffing and disorganization among staff can lead to mix-ups between patients’ drugs. Taking another patient’s drugs can have detrimental effects on health, and may even cause death. The study also noted that the more prescribing physicians a patient had, the more likely polypharmacy was to occur. This can be attributed to that fact that care facilities may not be properly documenting medical records. In terms of administration and management, documentation of medical charts is extremely important. All attending physicians must be able to clearly and easily see every medication that a patient is taking, in order to assess the costs and benefits of prescribing additional drugs.
Unfortunately, not all skilled nursing facilities have your loved one’s best interests at heart. What you can do is make frequent visits to check up on your loved one’s health and well-being. It is recommended that you have a general awareness of medications that are more likely to cause adverse drug reactions and overdoses. Also ensure to assess the facility’s staffing levels and closely monitor nurses, because tampering with patients’ drugs can sometimes occur in healthcare facilities.