The problem with oversedation in United States nursing homes
Kansas is one of six states spotlighted in a new report on the overuse of anti-psychotic drugs to sedate nursing home residents.
The report compiled by Human Rights Watch notes Kansas’ status as one of the states with the highest percentage of nursing home residents on the drugs, which are not approved to treat dementia and can have dangerous side effects.
“There’s a number of states, Kansas among them, that have a very high proportion of residents being given these drugs without an appropriate diagnosis,” said Hannah Flamm, a Human Rights Watch fellow who worked on the report.
Human Rights Watch said it visited 109 facilities, including 20 in Kansas, for its report, “They Want Docile: How Nursing Homes in the United States Overmedicate People with Dementia.” The other facilities were in Texas, California, Illinois, New York and Florida.
The group’s researchers interviewed dozens of nursing homes residents, family members, attorneys, advocates, government officials and nursing home administrators and employees. In 24 facilities the researchers were “asked to leave shortly after arriving” and at others the staff tried to keep them from interviewing residents, in some cases saying the residents were not competent to consent to interviews.
The federal government launched a campaign in 2012 to curb nursing homes’ use of anti-psychotic medications. Human Rights Watch analyzed Medicare data and found that all states have had at least some reduction between 2011 and 2016, but Kansas was toward the bottom of the pack in how much it improved its rates, going from about 23.8 percent to 18.2 percent.
The Star reported on Kansas nursing homes’ over-medication problem in a November story that included a database of the rates of use for individual facilities.
On average, 20 percent of all Kansas long-term nursing home residents received an anti-psychotic medication at some point in 2016, tying it for the highest rate in the country with Oklahoma and Mississippi.
And it could become a more prevalent issue. The number of older Americans is expected to double by 2060, which will put a bigger strain on nursing homes and care facilities in the coming years, particularly since the number of people with Alzheimer’s is expected to triple to 15 million by 2050.
Physical restraints not allowed
The rise of anti-psychotic use began decades ago, when nursing homes stopped using physical restraints to keep residents under control. Nursing home representatives say the medications are used out of concern for residents’ safety, not as a convenience for staff.
Katie Smith Sloan, the president and CEO of LeadingAge, said her group’s member homes, which are non-profits, tend to have higher staffing levels and that several “were recognized as exemplars in the practice of non-med management of dementia.”
She also said there were factors outside of nursing facilities’ control keeping them from further reducing anti-psychotic use, including increased commingling of older people with dementia and older people with mental health problems.
“The real core to the problem is inadequate access to meaningful mental and behavioral health services and the dollars to fund (them),” Sloan said. “Medicaid funding is grossly inadequate and there are few providers available — regardless of payer source.”
But the Human Rights Watch investigation found that the medications are often used to sedate nursing home residents rather than treat a legitimate mental health condition. Sometimes the residents and their loved ones aren’t informed that they’re on anti-psychotic drugs or that the drugs carry risks, including increasing the odds of a person falling down. That goes against the principle of informed consent for medication.
“Entering a nursing home does not mean a person gives up the rights they otherwise have,” Flamm said.
Kansas does not require informed consent, Human Rights Watch found. Kansas’ administrative regulations for all adult care homes, including nursing facilities, provide for the right to “refuse treatment” only.
Kansas Advocates for Better Care, an advocacy group for nursing home residents, has recommended that families ask facilities to voluntarily sign forms outlining when their loved ones can be medicated and with what.
Attending to their needs
The federal government started tracking the off-label use of anti-psychotic medications in nursing homes in 2011. Since then, Kansas has always ranked at or near the top in percentage of medicated residents, suggesting there are thousands of residents in the state’s certified nursing facilities who have been given drugs that aren’t medically indicated for them, and could actually harm them.
Ashley Plummer, a nurse who has worked in several Kansas nursing homes and talked to the researchers, said in most cases the drugs wouldn’t be necessary if nursing facilities had more people making sure residents aren’t hungry, thirsty, in pain or needing to use the restroom.
“When it comes down to it a lot of what I see is an issue of short staff or not educated staff,” Plummer said. “Nine times out of 10 these behaviors are needs not being met. If you don’t have the staff that can find the root cause of the issue, you’re just masking the communication by doping it up.”
Human Rights Watch recommended that government officials enforce informed consent laws, impose more financial penalties when they find facilities misusing anti-psychotics and institute more minimum staffing requirements.
Groups that represent nursing homes told Human Rights Watch they oppose minimum staffing measures.
David Gifford, the senior vice president for quality and regulatory affairs for American Health Care Association, said the group is pleased with the progress nursing homes have made since the federal campaign began. In the five years that followed, more than half of his group’s member homes met the 30 percent reduction goal and the national average fell from 25.3 percent of residents on anti-psychotics to 16 percent.
He said further reductions have been complicated by the high numbers of residents who come into nursing homes already on the drugs after hospital stays.
“Our challenge is getting the family and physicians to feel comfortable discontinuing the medications,” Gifford said.
But Flamm said she had talked to several administrators and employees in Kansas nursing facilities that had been able to reduce their use of anti-psychotics to almost zero. She said they told her that it not only didn’t cause them more problems, it actually prevented them.
“They over and over again told me they were surprised at how much easier it was to care for residents,” Flamm said. “It improves the quality of life for residents and for staff.”