Drug overuse threatens nursing home residents. Routine prescribing of powerful medications occurs too often, our investigation finds
Last reviewed: December 2010
More than five years after the Food and Drug Administration warned that drugs routinely prescribed to nursing-home residents posed serious threats, including an increased risk of death, inappropriate use remains high, according to a recent analysis by the American Society of Health-System Pharmacists (ASHP). The project is part of a CRH Best Buy Drugs ongoing investigation of medication prescribed “off-label.”
The drugs in question, atypical antipsychotics, are approved by the FDA to treat bipolar disorder and schizophrenia. But they’re frequently used off-label to control agitation, aggression, hallucinations, and other behavioral symptoms in elderly patients with Alzheimer’s disease or other forms of dementia. There are no FDA-approved drugs to treat these behavioral symptoms, but doctors can legally prescribe any drug for any reason they deem appropriate.
But those medications—such as aripiprazole (Abilify); olanzapine (Zyprexa); quetiapine (Seroquel); and risperidone (Risperdal and generic)—pose substantial risks, especially to older people, that include diabetes, movement disorders (some permanent), pneumonia, stroke, weight gain, and even sudden cardiac death.
“There is limited evidence for the efficacy of these medications and evidence of significant safety risks,” says E. Ray Dorsey, M.D., an associate professor of neurology at the Johns Hopkins University School of Medicine. “In addition, many of the people receiving them have limited capacity to weigh the risks and benefits of taking them.”
According to FDA estimates, the rate of death among elderly dementia patients with behavioral problems who received antipsychotics was about 4.5 percent over the course of a typical 10-week controlled trial, compared with about 2.6 percent for a placebo group. This prompted the FDA to require black-box warnings—the strongest type—to be added to the labeling of atypical antipsychotic medications in 2005. The FDA broadened the warning in 2008 to include the labels on “typical” or older antipsychotics, including chlorpromazine (only available as a generic now) and haloperidol (Haldol and generic).
What measures should you try first?
In a study published in the 2010 Archives of Internal Medicine, researchers found that the use of antipsychotics often began during a patient’s first week in a nursing home. That suggests that behavioral interventions—the treatment of choice—are used minimally, if at all.
“The patient is scared and upset in a strange environment, and the caregiver may lack training in how to respond,” explains Kenneth Brubaker, M.D., a geriatrician and board member of the American Medical Directors Association (AMDA), a group of health professionals who work in nursing homes and assisted living facilities.
“I would advocate that a family member be present as much as possible during the adjustment period, because that’s the patient’s only contact with reality,” says Brubaker. “Having frequent phone conversations between patient and family help, as do looking through family photo albums together or compiling a DVD of the patient’s life story to remind them of the past.”
Frontline caregivers—who deal directly with residents with dementia-related behavioral problems—often have limited skills in using such approaches, Brubaker says. At those nursing homes, according to Brubaker, agitated new residents are likely to be quieted with antipsychotic drugs in lieu of family photos.
This off-label drug use report is made possible through a collaboration between Consumer Reports Best Buy Drugs and the American Society of Health-System Pharmacists. This is the18th and 19th in a series based on professional reports prepared by ASHP.
These materials were made possible by a grant from the state Attorney General Consumer and Prescriber Education Grant Program, which is funded by a multistate settlement of consumer fraud claims regarding the marketing of the prescription drug Neurontin (gabapentin).
My response to: Anyone have experience with Psychiatrists being used for LBD patient?
I received this email this morning from LBDcaregivers@yahoogroups.com. My response follows this copy of the email.
Anyone have experience with Psychiatrists being used for LBD patient Posted by: "drh488" Wed Nov 18, 2009 3:17 pm (PST)
Today we had a Psychiatric nurse visit Mom. By the time she left, she had my mother so emotionally upset that she is ready to go back to a nursing home and die. She brought up things to my mother that happened 30 years ago and hasn’t been discussed in 20 years. Our battle with the outside caregivers has turned into a social worker telling us that WE have become Lewy body dementia. Our extreme efforts to make people understand the disease has taken the place of taking care our mother. Our mother does best when she has structured days. Up at 6, breakfast at 8, regis at 9, lunch at noon….etc. Anything out of that structure causes problems with her. This company sends occ. therapy, phys therapy, and a nurse. We have explained time and time again that our Mom needs structure. To no avail we wont here from them for 3-4 days then they call saying "We are on our way". Next thing you know, 3 people in one day unexpected. My sister is so frustrated. Psych nurse told my Mom that she has LBD, what it is and everything. Brought up old memories of my sister dying, my dad dying. Then she leaves with my mom all upset and my sister to deal with it. Psych nurse wont be back for 2 weeks. I’m calling my Mom’s neurologist tomorrow to see if she should be talking to this psycho nurse…no pun intended….It seems to me that it is more destructive than constructive. Interested if anyone has had similar experiences Thank You
I felt appalled as I read this post. It goes to show that not all educated individuals use good old fashioned common sense. Even a small child realizes something isn’t right when they see someone being hurt and being in distress.
As an aside, I should mention that dementia is not only a neurological diagnosis but is also an official psychiatric diagnosis.
Unfortunately, in spite of being taught to first DO NO HARM to a patient, medical professionals don’t always have good common sense either. One doesn’t always learn certain things from medical, psychology and nursing books.
Having said this, there is not excuse for someone to get someone upset like this. Psychiatrists, psychologists and psychiatric nurses are taught that certain mental health diagnoses should not be treated with traditional psychotherapy such as schizophrenia and dementia. These disorders are treated with supportive psychotherapy, not with insight-oriented psychotherapy as described in the email.
What good does it do to dredge up the past with someone who has dementia? How can it be helpful? I certainly don’t know. However, if an individual unsolicitedly brings up past memories, that is fine. They can be dealt with in a supportive way whether positive or negative. And reminding someone of past positive memories can be therapeutic as well. But to stir up past memories in any of us against our will is certainly cruel in my opinion.
So, yes, this behavior is undoubtedly more destructive than constructive. Definitely confront the involved providers and request them to discontinue this type of communication and involvement. If it doesn’t stop, go to the next level, etc. If it continues, and if it is possible, go somewhere else! If it smells like a duck, quacks like a duck and walks like a duck then it is a duck………….
This makes me wonder. How many of all caregivers, professional and non-professional unwittingly aggravate and/or cause some of the argumentativeness, irritability and combativeness seen in the dementia population?
I’d be interested to hear of others’ thoughts and opinions.
Warmly………….David
A must read for caregivers — “A person immobilized by dementia has the potential to change a life with merely a glance or a touch”
A must read article for caregivers! This article brilliantly describes the stigma of being both elderly and having dementia. Yes, those of us with dementia can still have an impact of others. More…
It reminds me so much of Louise Morse’s book, “Could it be dementia?”
Warmly…….David
Sex and Dementia: Shrouded by Taboo
A man with Alzheimer’s and his wife of many years finish lovemaking when he rolls over and tells her, “You’d better hurry up and get your things because my wife will be home soon." ……….
This comes from a thought provoking article here. I believe this is a subject which needs to be addressed on many levels. Life doesn’t stop when someone becomes demented. All of our physiological needs persist throughout the course of our lives..
We all follow Maslow’s hierarchy of needs. Click on the picture to open it up. Notice that the red portion of the triangle is the foundation of our being.
Physiological needs include:
Tell me what you think…………..David
11 Types of Music that Soothe Dementia
by Paula Spencer, Caring.com senior editor
Why is it that I can remember the lyrics of every awful ’70s pop tune I catch the merest snatch of while turning a radio dial, but not the name of the street two miles away? The answer is good news; that is, if you spend time with someone who has Alzheimer’s, dementia, or Parkinson’s Disease.
Music lodges uniquely deep in the recesses of the brain–and therefore can still be tapped long after other abilities have failed. Musical memories are a complicated code of primal emotions, cognition, movement, and language. It both calms and provides sensory and social stimulation. But there’s an even better reason to bring singing, listening, playing, and dancing into the life of someone with a dementing illness: To provide them with the deep pleasure and reassurance brought by enjoying moments of wholeness and clarity.
For a person with a neurological impairment, music can “stimulate a sense of identity as nothing else can,” says neurologist Oliver Sacks, who writes about the evocative powers of music in last year’s bestseller, Musicophilia, and in the November issue of O magazine.
Long-term care facilities know this and use “music therapy.” But it struck me that home caregivers or family members might not realize this remarkably effective tool that’s right under their noses–or rather, ears.
Some ideas to try:
Heyday favorites. Unsure what the person has long liked (jazz, big band, classical)? Google “music era” with the decades during which the person was a teenager or in his or her 20s (1920s, 1940s, and so on).
Christmas carols. ‘Tis the season (so stores already tell us). Start with classics: Bing Crosby, Nat King Cole, Elvis, Rudolph the Red Nosed Reindeer.
Nursery rhymes. When I was a brand-new mother, I didn’t know any proper lullabies. So after I sang all the carols and Beatles songs I could think of, I went through Mother Goose. You’d be surprised how sing-songy and satisfying rhymes like “Jack and Jill” and “Hey Diddle Diddle” can be.
Hymns. Ask to borrow a hymnal from a place of worship to help you sing or play familiar standards on the piano.
Funny songs. Add the benefits of laughter with corny tunes like Tiny Tim’s “Tiptoe Through the Tulips” or my dad’s old favorites, “Mares Eat Oats” and “Hello Mudda, Hello Fadda” (by Allan Sherman).
Musicals. Listen to a soundtrack, or rent the movie version. Turn it up when Julie Andrews croons “My Favorite Things.”
TV-show theme songs. Google those words and you’ll find many CDs. After all, tunes like Archie and Edith Bunker’s “Those Were the Days” duet were the soundtrack for many an evening.
TV shows about music. One of my Dad’s favorites is “Don’t Forget the Lyrics” (Fox). There’s also “American Idol.”
Wandering minstrels. Sounds farfetched but it’s fabulous if your area happens to have a wonderful program like “Music for Seniors,” which musician and caregiver Sarah Martin McConnell founded in Nashville to bring area performers to seniors in care locations, day centers, and at home. (She says it’s the only such program she knows of, but she’d love to see it nationwide. As for me, I love it!)
Musical instruments. If the person played one, he possibly still can. Alternatives: Plucking a child’s zither or working a tambourine or xylophone.
Don’t forget to sing, use hand motions like clapping, and dance. People with Parkinson’s disease especially benefit from dancing.
Warmly………David
Is vitamin D deficiency linked to Alzheimer’s disease and vascular dementia?
There are several risk factors for the development of Alzheimer’s disease and vascular dementia. Based on an increasing number of studies linking these risk factors with Vitamin D deficiency, an article in the current issue of the Journal of Alzheimer’s Disease (May 2009) by William B. Grant, PhD of the Sunlight, Nutrition, and Health Research Center (SUNARC) suggests that further investigation of possible direct or indirect linkages between Vitamin D and these dementias is needed.
Low serum levels of 25-hydroxyvitamin D [25(OH)D] have been associated with increased risk for cardiovascular diseases, diabetes mellitus, depression, dental caries, osteoporosis, and periodontal disease, all of which are either considered risk factors for dementia or have preceded incidence of dementia. In 2008, a number of studies reported that those with higher serum 25(OH)D levels had greatly reduced risk of incidence or death from cardiovascular diseases.
Several studies have correlated tooth loss with development of cognitive impairment and Alzheimer’s disease or vascular dementia. There are two primary ways that people lose teeth: dental caries and periodontal disease. Both conditions are linked to low vitamin D levels, with induction of human cathelicidin by 1,25-dihydroxyvitamin D being the mechanism.
There is also laboratory evidence for the role of vitamin D in neuroprotection and reducing inflammation, and ample biological evidence to suggest an important role for vitamin D in brain development and function.
Given these supportive lines of evidence, Dr. Grant suggests that studies of incidence of dementia with respect to prediagnostic serum 25(OH)D or vitamin D supplementation are warranted. In addition, since the elderly are generally vitamin D deficient and since vitamin D has so many health benefits, those over the age of 60 years should consider having their serum 25(OH)D tested, looking for a level of at least 30 ng/mL but preferably over 40 ng/mL, and supplementing with 1000-2000 IU/day of vitamin D3 or increased time in the sun spring, summer, and fall if below those values.
Writing in the article, Dr. Grant states, "There are established criteria for causality in a biological system. The important criteria include strength of association, consistency of findings, determination of the dose-response relation, an understanding of the mechanisms, and experimental verification. To date, the evidence includes observational studies supporting a beneficial role of vitamin D in reducing the risk of diseases linked to dementia such as vascular and metabolic diseases, as well as an understanding of the role of vitamin D in reducing the risk of several mechanisms that lead to dementia."
More information: The article is "Does Vitamin D Reduce the Risk of Dementia?" by William B. Grant, Ph.D. It is published in the Journal of Alzheimer’s Disease 17:1 (May 2009).
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Has anyone approached you in a public area and offered FREE services, groceries, or other items in exchange for your Medicare number?
JUST WALK AWAY!
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