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,
The Hartford Courant reports.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, Charlene Harrington, an expert on nursing home quality and professor of sociology and nursing at the University of California-San Francisco, tells the Courant. "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."
The disclosure comes amid ongoing debate over antipsychotics and whether some docs prescribe them too readily. In some states, the meds are given to populations for which they were never approved (look here and here). As reported previously, a growing number of states are suing various drugmakers over marketing that led Medicaid programs to pay unnecessarily for the meds.
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, the paper writes. 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. A recent report indicated this is a growing concern in Florida.
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," Barbara Cass, the state health department's program manager for the Medicare survey program, tells the Courant.
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 tells the paper. "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."
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, the paper reports.