LISA CHEDEKEL | Courant Staff Writer, "State's Nursing Homes Might Be
Overusing Antipsychotics", Hartford Courant, March 3, 2008,
Link: http://www.courant.com/news/health/hc-druggedresidents0302.artmar02,0,2380275.story

Connecticut's nursing homes dole out antipsychotic drugs to residents
who do not have psychotic disorders at one of the highest rates in the
country, raising questions about whether the medications are being
used to subdue agitated patients because of a lack of staffing and
attention to alternate treatments.

Federal data from the Centers for Medicare & Medicaid Services show
that since 2005, Connecticut has consistently ranked in the top four
states in the prevalence of antipsychotic drugs dispensed to nursing
home residents who have no psychotic or related conditions. In the
most recent quarterly report, through September 2007, only Louisiana
had a higher prevalence rate than Connecticut, where more than 26
percent of residents who lacked an appropriate psychiatric diagnosis
were prescribed antipsychotics.

Nationally, the prevalence rate is 19.8 percent, with several states,
such as Florida, Pennsylvania and New Jersey, well below that average.

"This is not a good indicator" for Connecticut, said Charlene
Harrington, an expert on nursing home quality and professor of
sociology and nursing at the University of California-San Francisco.
"One of the main factors [for a high medication rate] is not having
enough staff. If patients are having behavioral problems, it's easier
to give them a pill to keep them quiet" than to hire more staff. "It's
cheaper. They'll sleep a lot."

Nursing-home staffing is now a focus of state lawmakers, who are
weighing proposals that would update the state's minimum staffing
standards to nationally recommended levels. The existing standards are
more than 25 years old and rank among the least stringent in the
country. The staffing proposals were prompted by a series in The
Courant that detailed the troubled patient-care and financial history
of one of the state's largest chains, Haven Healthcare, which filed
for bankruptcy after the stories appeared.

Federal data from the past three years show that Connecticut has
ranked highest or second-highest among states in the prevalence of
antipsychotic use among "low-risk" nursing home residents, defined as
those who do not exhibit cognitive impairment and behavioral problems.
In the most recent reporting period, 23.3 percent of low-risk
residents were receiving antipsychotics, compared with the national
average of 16.5 percent.

Among "high-risk" residents who do exhibit those problems, Connecticut
prescribes antipsychotics at the highest rate in the country -- 55.2
percent, compared with the national average of 42.5 percent, according
to data from the most recent reporting period.

The Nursing Home Reform Act of 1987 mandates that residents be free
from "chemical restraints" imposed for the purposes of discipline or
convenience. Federal guidelines allow nursing homes to administer
antipsychotic drugs to residents with dementia-related behavioral
symptoms, but they require that residents meet specific clinical
criteria and receive gradual dose reductions and behavioral
interventions in an attempt to wean them off the medications.

Although the newer antipsychotics, called atypicals, are approved only
for bipolar disorder and schizophrenia, doctors routinely prescribe
them "off-label" to quiet behavioral problems associated with dementia
or Alzheimer's disease. The use of such drugs in nursing homes has
grown in recent years, despite studies questioning their benefits and
highlighting their risks.

The most commonly prescribed antipsychotics carry Food and Drug
Administration "black box" warnings that elderly dementia patients
using them face an increased risk of death. In addition, studies have
shown that the drugs most commonly prescribed off-label for
Alzheimer's patients are no more effective than placebos for most
people, and carry side effects that include confusion, sleepiness and
rigidity, which can increase the risk of falls.

State public health officials say they are not sure why Connecticut
nursing homes have a high rate of dispensing antipsychotics to
residents who lack an appropriate diagnosis. They say that their
prevalence data might be better reported than other states, and they
note that the health department has been aggressive about citing homes
for medicating residents unnecessarily.

Some health officials suggest that the prevalence rate is high because
Connecticut has a relatively large proportion of residents who are
over age 80 and who have dementia-related problems.

"One of the reasons could be we have a large number of seniors in our
[nursing home] population. Our population is getting older. Our
dementia numbers are probably increasing," said Barbara Cass, the
state health department's program manager for the Medicare survey
program.

But Connecticut nursing homes do not have especially high numbers of
residents diagnosed with dementia or other psychiatric conditions in
comparison with other states, according to federal data. In 2006, 46
percent of Connecticut's nursing home residents had a dementia
diagnosis -- slightly higher than the national average of 45 percent,
but lower than 22 other states. About 15 percent of Connecticut's
nursing home residents had other psychiatric diagnoses, lower than the
national average of 20.5 percent.

Those figures account for residents with specific diagnoses, but they
do not include all residents who exhibit dementia-related behavioral
problems.

Dr. Harry Morgan, a geriatric psychiatrist in Glastonbury, said he was
disturbed to learn that Connecticut ranks high in its rate of
dispensing antipsychotics to residents without diagnoses. He said that
the protocol he advocates as a consultant to nursing homes calls for
clinicians to try behavioral interventions and examine possible
physical causes for agitation before considering antipsychotics.

"There are times in which patients with dementing illnesses are in
such distress, to do nothing would be inhumane," Morgan said. "But in
some nursing homes, what you see is a knee-jerk reaction -- they'll put
someone on a neuroleptic [or antipsychotic] ... in hopes of a quick fix
tonight."

"The use of these medicines can be appropriate, but it is not
appropriate to use them as an alternative to adequate staffing,"
Morgan said. "People shouldn't approach them as a first-line
treatment. ...We have to work to drive down the usage of antipsychotic
drugs."

Toby Edelman, an attorney with the Center for Medicare Advocacy Inc.
in Washington said that in the 20 years since the nursing-home reform
law was passed, the industry has focused more on reducing the
prevalence of physical restraints than on limiting chemical
restraints.

Medication "is not as visible as physical restraints, so it's used as
a substitute," Edelman said. "That's hardly what the [reform act] was
intended to do."

Edelman and Harrington said that a high prevalence of antipsychotic
use in a nursing home can be an indicator of inadequate staffing. Non-
pharmacological interventions for residents with dementia, such as
recreational activities, exercise and one-on-one attention, require
extra staff.

"You have to have the time to spend with people," Harrington said.

On average, nursing homes in Connecticut provide about 3.7 hours of
care per resident a day -- 1.4 hours by licensed or registered nurses,
and 2.3 hours by certified nursing assistants.

Other states have taken steps to boost staffing to levels recommended
in a study commissioned by the federal government: 4.1 hours of care
per resident a day.

Connecticut homes have had little incentive to boost staffing, in part
because state law requires only 1.9 hours of nursing care a day. The
state health department has rarely ordered individual homes to
increase their staffing levels.

But federal data do suggest that Connecticut is more aggressive than
other states in citing nursing homes for administering unnecessary
antipsychotic drugs and other medications.

In the latest surveys, state health inspectors cited 21.7 percent of
Connecticut's 244 licensed homes for administering "unnecessary drugs"
to residents, a rate higher than the regional average of 14.7 percent
and the national average of 18 percent. Although unnecessary drugs can
include all kinds of medication, the citation frequently is issued for
improper use of psychoactive drugs.

Cass, the health department program manager, said that Connecticut has
been "very astute" in identifying unnecessary drug violations, in part
because the state uses a more in-depth inspection process than many
other states. In each nursing home, inspectors closely review the
medication records of a sampling of residents to ensure that there are
appropriate diagnoses, she said. In addition, the health department
flags homes with high rates of prescribing antipsychotics and conducts
"more focused reviews" of those facilities.

Inspection data show that the state has issued more than 110 citations
to nursing homes since October 2005 for administering unnecessary
drugs. Eleven homes have been cited twice for that violation, with the
second citation coming within a year of the first. Among the homes
cited twice was Wethersfield Health Care Center, which was included on
a recent federal list of 54 of the most poorly performing nursing
homes nationwide.

Eight homes owned by Haven Healthcare have been cited for unnecessary
drugs in the past two years, federal records show. Haven's chain of 15
Connecticut homes filed for bankruptcy in November after The Courant's
stories detailed the chain's repeated patient-care deficiencies, lower-
than-average staffing and serious financial problems.

The improper use of psychotropic drugs at one Haven home in Torrington
led the health department to issue a consent order against the home in
December 2006 that mandated closer monitoring of residents receiving
antipsychotics. State health inspectors had cited the home for seven
cases in which it failed to justify the use of antipsychotic,
antidepressant or sedative medications, or to monitor residents for
side effects.

In one of those cases, a resident receiving five such medications,
without an appropriate diagnosis, was found to be in such declining
health that hospice was called -- until a physician was alerted and
ordered a reduction in the drugs. The resident's mental state then
rebounded: "The agitation and anxiety are gone, the resident is much
more alert [and] vital signs are stable," the state health inspection
report says.

More recently, in November 2007, state health inspectors imposed a
consent order and two years' probation on Haven's home in New Haven
for myriad violations, among them failing to justify and monitor the
use of antipsychotic medications prescribed to two residents. The New
Haven home also was cited for low staffing levels.

Nationally, the rate of prescribing psychoactive drugs in nursing
homes has been rising in recent years, with a 2005 study showing that
antipsychotic use in 2000-01 had reached the highest level in more
than a decade. That study, headed by a University of Massachusetts
Medical School researcher, found that about one-third of nursing home
residents receiving antipsychotics had "inappropriate indications" for
the drugs.

In 2005, the taxpayer-funded Medicaid program -- the main payer for
drugs prescribed in nursing homes -- spent more than $5 billion on
antipsychotics such as Risperdal and Seroquel, which retail for
several dollars per pill.

Since the FDA warnings, some doctors increasingly have turned to
antidepressants to treat the agitation and psychotic symptoms
associated with dementia. Morgan said that depression can be an
underlying cause of agitation, and he noted that antidepressants don't
carry the adverse side effects -- or expense -- of antipsychotics.

Morgan said that although most Connecticut nursing homes have a large
proportion of residents with dementia-related symptoms -- 50 percent to
70 percent, in his estimation -- many homes "don't think of themselves
as dementia-care facilities, in terms of having special expertise" or
extensive training for staff. That needs to change, he said.

"We have to begin to shift the model of dementia care away from
skilled-nursing facilities, so that we also focus on behavioral
interventions [and] recreational and interpersonal activities," Morgan
said. "Staffing certainly has to be looked at, but so does the
training of that staff."