http://www.healthsentinel.com/org_news.php?event=org_news_print_list_item&id=047

Roman Bystrianyk, "The Drugging of Seniors in Nursing Homes", Health
Sentinel, July 8, 2005,

In 2001, Medicaid spent over $3 billion dollars for antipsychotic
drugs, compared with $2.7 billion for antimicrobial drugs, $2.4 billion
for cardiovascular drugs, and $1.8 billion for antidepressants.
Prescribing of antipsychotic drugs has been increasing in nursing
homes, but with little information on the appropriateness of such
prescribing. A June 2005 study in the Archives of Internal Medicine
examines the quality of antipsychotic drug prescriptions in
approximately 2.5 million Medicaid beneficiaries in nursing homes.

The appropriateness of antipsychotic drug prescribing in nursing homes
has been an issue since 1986 when the Institute of Medicine issued a
report indicating widespread misuse of antipsychotic medications to
"sedate or discipline" people in nursing homes. The following year
Congress passed a law providing for more oversight of conventional
antipsychotic medications. Studies examining those early governmental
efforts found a decrease in the numbers of patients receiving these
medications.

Since then a second-generation of antipsychotic drugs, or
"atypicals" have been introduced including clozapine, risperidone,
olanzapine, quetiapine, fumarate, ziprasidone, and aripiprazole. With
their introduction the decrease in antipsychotic medication
prescriptions has reversed course and has now increased. In 1995, 16%
of nursing home residents were receiving antipsychotics and by 1999 the
number had increased to 19.4%.

Most atypical medications receive FDA approval for use in patients with
diagnosed schizophrenia, but increasingly these medications are
prescribed for other conditions with much less evidence. Also, although
these medications are widely promoted as causing less movement
disorders as the older medications, they have shown other serious
problems such as falls, extreme drowsiness, and abnormal walking. "In
the face of limited evidence, the wider use of antipsychotics in
nursing homes deserves attention to understand the extent of new
indications and new patient populations and the ability of established
guidelines to protect nursing home residents from inappropriate use."

In their analysis the study authors found that "more than 1 of every
4 (27.6%)" nursing home resident receiving Medicare receives
antipsychotic medications. The average amount of time per year that a
person was on antipsychotics was just over half a year at 6.4 months.

The study also found that "over half (58.2%)" of these residents
received antipsychotic medications that exceeded the maximum
recommended dose of the medication, received duplicate therapy, or had
inappropriate indications for the medication in the first place
according to guidelines.

More than 200,000 nursing home residents received antipsychotic therapy
but had, "no appropriate indications for use." Most of the out of
guideline prescriptions were for memory problems, restlessness,
unsociability, uncooperativeness, indifference to their surroundings,
or depression. Prescriptions for these conditions was strongly
discouraged by a recently assembled expert panel on the appropriate use
of antipsychotics in seniors, which also noted the need for more
guidance in use of these medications.

Despite being prescribed these medications, nearly 40% still regularly
resisted taking medications or eating meals. Nearly 40% also made
disruptive noises such as screaming, disrobing in public, and throwing
food. The authors note that, "our study cannot easily explain the
lack of improved stable behavior patterns with appropriately prescribed
antipsychotics." They also note that other study authors have also
"failed to detect improvement in patient outcomes" with the
expanded use of atypical medications. One study found no improvement in
admissions to hospitals or long-term care facilities despite California
Medicaid increased spending of atypical mediations by 670% over 8
years.

This study raises serious questions about the current use of
antipsychotics in nursing homes while detecting the highest level of
antipsychotic use in nursing homes in over a decade. The authors
conclude that, "Most atypicals were prescribed outside the
prescribing guidelines and for doses and indications without strong
clinical evidence. Failure to detect a positive relationship between
behavioral symptoms and antipsychotic therapy raises questions about
the appropriateness of prescribing."

SOURCE: Archives of Internal Medicine, June 13 2005