Elderly over prescribed with drugs

In the United States, elderly patients with dementia are too often prescribed anti-psychotic drugs to calm their disruptive behaviour, a costly and risky practice that should end, experts said.

Instead, more care should be taken to determine why dementia patients may be acting up and treat those underlying causes, lawmakers were told at a hearing of the Senate Committee on Aging.

As the baby-boomer generation ages, it is imperative to address the overuse and misuse of antipsychotic drugs among nursing home patients, said Daniel Levinson, Health and Human Services Inspector General.

Levinson said recent government audits have raised concerns about the use of antipsychotics by elderly people with dementia in nursing homes, raising their risk of death and wasting money for the US healthcare system.

Prescriptions wrongly paid for

For instance, more than half of such prescriptions were wrongly paid for in 2007 by government Medicare because the patients did not exhibit symptoms of schizophrenia or bipolar disorder, amounting to about R1.9 billion in waste.

One audit showed 14% of nursing home residents had Medicare claims for antipsychotic drugs, he said.

But another panel member, Toby Edelman, senior policy attorney in the office of the Centre for Medicare Advocacy, said that audit's estimate was low because it only included some kinds of anti-psychotics.

Nursing facilities' self-reported data indicate that in the third quarter of 2010, 26.2% of residents had received antipsychotic drugs in the previous seven days. That is approximately 350,000 individuals, she said.

Nursing facilities understaffed

"Facilities reported they gave antipsychotic drugs to many residents who did not have a psychosis, including 40% of patients at high risk because of behaviour issues."

Edelman also pointed out that this issue is far from new, and that the same Senate committee had issued a report on the misuse of drugs in nursing homes back in 1975, and held a workshop on the topic two decades ago.

The practice persists, even though it is against federal law, because of serious understaffing in nursing facilities, high turnover of staff, and aggressive off-label marketing of anti-psychotic drugs, she said.

The pharmaceutical giant Eli Lilly in 2009 paid a nearly R12.4 million settlement, in which it admitted no wrongdoing, for off-label promotion of its drug Zyprexa as a treatment for dementia. The drug is FDA-approved for bipolar disorder and schizophrenia.

Penalise for inappropriate prescription

According to Tom Hlavacek, executive director at Alzheimer's Association's south eastern Wisconsin chapter, elderly people with dementia are sometimes prescribed these potent drugs for behaviours that have other causes.

Urinary tract infections, tooth decay, arthritic pain, or simply moving a patient from one place to another can lead to agitated behaviours.

Our experience indicates that these care transitions can exacerbate behaviours and often lead to escalating drug treatments, he told lawmakers.

Experts said solutions could include creating stronger penalties for inappropriate prescribing, and a renewed focus on trying non-pharmacological approaches to a problem first.

Behaviour is not a disease

Most doctors treat unwelcome behaviour in all settings as a disease that requires medication. These drugs are used as chemical restraints, said Jonathan Evans, a doctor who specialises in caring for frail elders.

Behaviour is not a disease. Behaviour is communication. And in people who have lost the ability to communicate with words, the only way to communicate is through behaviour, he added.

Good care demands we figure out what they are telling us and help them.

(Sapa, November 2011) 

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