Staff Writer

Maine is ahead of the curve in a movement to reduce the medication of elderly people in nursing homes.

A Food and Drug Administration audit in May found dozens of nursing homes failed to comply with federal regulations designed to prevent overmedication, and that certain drugs were being prescribed for uses not approved by the FDA or not qualified for Medicare patients.

The FDA had warned doctors since 2005 they could increase the risk of death in patients with dementia by overprescribing the most common antipsychotics — such as Risperdal, Zyprexa, Seroquel, Geodon, Abilify and Invega — because of an increased risk of heart attacks or pneumonia.

The May audit found that “most alarming, 88 percent of the time (antipsychotic) drugs were prescribed for elderly patients with dementia, a population the FDA has warned faces an increased risk of death from this class of drugs.”

The report also found:

* 14 percent of nursing home residents, or nearly 305,000, had Medicare claims for these antipsychotic drugs.

* Half of the antipsychotic drug claims for which Medicare paid should not have been covered because the claimed drugs were not used for medically accepted indications.

* For one in five residents, nursing homes dispensed antipsychotics in violation of government standards. For example, the prescribed dose was too high or residents were on medication for too long.

Antipsychotics are given to hundreds of thousands of elderly nursing home patients in the United States to pacify aggressive and paranoid behavior related to dementia. The medications are meant primarily to help control hallucinations, delusions and other abnormal behavior in people suffering from schizophrenia and bipolar disorder.

But the drugs can limit seniors’ ability to effectively communicate, socialize or participate in everyday life.

Maine is one of 14 states that uses the Quality Indicator Survey, a two-stage process state surveyors use to review specific nursing home requirements and investigate possible violations of federal rules.

Quality control

Anne Flanagan, assistant director of the Maine Department of Health and Human Services Division of Licensing and Regulatory Services, said Maine switched to the survey system two years ago.

“We have 109 nursing homes in Maine, and they have a survey that takes place once a year,” Flanagan said. “It’s unannounced by a team of specially trained surveyors who go into the facilities and review what’s going on with the residents.”

One of the things specifically reviewed is the use of drugs. Flanagan said the process puts Maine “ahead of the curve, nationally.”

She said surveys take more than a week to complete. The teams select 40 residents in each facility as a sample group to evaluate. Medical records are reviewed and residents and their families interviewed.

“This helps identify residents who are oversedated,” she said. “It’s not limited to medical records. They also have interaction with the residents and if they’re not able to be interviewed, the family is sought out. Those families have an opportunity to weigh in on how they feel their relative is being medically managed.”

She said the public should feel reassured oversight is taking place in Maine on a regularl basis, specific to the issue of overmedicating the elderly.

“We can’t guarantee it’s never happened, but it isn’t something that is going without being noticed,” Flanagan said.

In addition to the annual surveys, she said her division investigates hundreds of complaints each year; only a small percentage has to do with overuse of drugs, she said.

Families of local nursing home residents have various concerns when it comes to drug use in nursing homes.

Kathy Arnott, of Sidney, said her husband’s aunt was in her 80s when she died from an overdose of pain medication in a Skowhegan nursing home.

“At the time, there was a new pain medication prescribed to her and she was only to be given half a dose, and they gave her a whole one,” Arnott said. “She went into cardiac arrest … what they called a narcotic overdose and ultimately she passed away a few days later.”

The use of antipsychotics varies from facility to facility, according to Jennifer Brown, residential care director at the MaineGeneral Medical Center’s Alzheimer’s Care Center in Gardiner.

‘Systematic unprescribing’

Brown said the approach at MaineGeneral facilities is to rid a patient of as many medications possible upon admittance, then reintroduce what is needed at the lowest possible dose to reach a desired effect.

“When someone is admitted here, we look at all their medication, then do a systematic unprescribing,” Brown said. “We always try to take away any medications that they really don’t need.”

She said family members rarely come to staff with concerns about the use of antipsychotics.

Rather than medicate an elderly client, nursing home officials first are using behavioral techniques.

Mark Rolfe, medical director of geriatrics at MaineGeneral, said trained staff “redirect” a patient who is agitated before antipsychotics are used in cases of Alzheimer’s or dementia.

“When someone starts to get agitated, there are techniques to get them to move on to the next subject. It might be by getting them into a different room to help them calm down,” Rolfe said. “They’ll try those techniques first before we would try antipsychotics.”

Brown said patients do better in a less restrictive environment.

“I would say when the person is really experiencing significant distress, they’re unable to sit down long enough to eat, can’t sleep, they’re extremely suspicious, paranoid,” she said, “you might consider using one of those medications, when nothing else helps. But we always try reassurance, redirection, validation of their concerns and talking them through it.

“We don’t argue with them; they don’t understand. We try to be in their moment, so to speak.”

Rolfe said Aricept and Namenda are the most common medications used for early dementia. When all other methods fail, he said staff will start a patient on the lowest possible dose of antipsychotics.

“We don’t want people to be oversedated, and if there’s any adverse effects, we stop the medication,” Rolfe said. “The federal government requires nursing homes to do gradual dosage reductions. These people aren’t started on these medications without their family members or guardians knowing the risks and benefits.”

“Sometimes, if they’re agitated, it may be something as simple as needing to use the bathroom,” she said. “Or they’re hungry or tired or they could be constipated. Those can bring out negative behavior. They just can’t verbalize it.”

Denis Culley, an attorney from Mercer, said his mom moved into the Alzheimer’s Care Center around 2008. When she arrived, staff did a full evaluation and found she was “on at least two of everything.”

“I think that sometimes happens with elderly dementia patients,” Culley said. “They end up seeing many different doctors and everybody has a shot at prescribing them something. That’s how they end up with a lot of medications.”

Culley said once staff gradually started removing the duplicated medications, his mother’s condition improved remarkably.

“She passed away later on, but I think her quality of life was a lot better with a more focused medical pharmaceutical regimen,” he said.

National trend

Since the FDA’s May audit, nursing homes nationwide have been rethinking their use of antipsychotics.

Izchak Kohen, a geriatric psychiatrist for North Shore-Long Island Jewish Health System in New York, surveyed nursing homes across the country and found 39 percent had decreased their use of the drugs since the warning.

Spending Medicaid — the largest payer of nursing home care in the U.S. — also indicates a shift.

For all age groups, in the 2006 fiscal year, antipsychotics drug bills totaled about $7.9 billion for Medicaid. The following year, it dropped to about $4.9 billion. Spending in 2008, the latest year for which data is available, totaled about $3.7 billion.

The increasing use of generics may have also helped bring the cost figure down. The addition of the Medicare prescription drug program, for which some Medicaid patients are also eligible, is also believed to have drawn down the spending figure.

Gail Hillstrom, administer of the Maine Veterans’ Home in Augusta, said the home also uses nonpharmaceutical interventions to reduce the use of antipsychotics.

“Whenever we find something that’s not working, we go back and sit down and look for other ways to do it better,” Hillstrom said. “We’re bringing in a nationally known speaker to talk specifically about these kinds of things, what we can do rather than give medication for bad behaviors and how to prevent those kinds of reactions in the first place.”

Mechele Cooper — 621-5663

[email protected]

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