Antipsychotics in Nursing Homes
Donna McCabe, DNP, GNP-BC, PMHNP-BC
Clinical Associate Professor
NYU Rory Meyers College of Nursing
The quality of care provided in nursing facilities in the United States has come under scrutiny once again. A recent investigative report published in the New York Times (September, 2021) revealed what appears to be a fraudulent practice of assigning false diagnosis of schizophrenia or other serious mental illnesses. The report alleges that these false diagnoses were utilized to justify the use of antipsychotic medications to treat the behavioral and psychological symptoms of dementia (BPSDs). Family accounts further report that these medications were given without their knowledge or consent.
BPSDs such as aggression, agitation, wandering, and yelling are common among persons living with dementia. The evidenced-based care for the BPSDs includes looking for underlying treatable causes and non-pharmacological approaches. The practice of utilizing antipsychotic medications to sedate and reduce behaviors has been an ongoing practice despite evidence of the medication’s ineffectiveness and potential harm.
The inappropriate use of antipsychotic medications among older adults living with dementia residing in nursing facilities has been a concerning practice that regulatory processes have tried to control for decades. The landmark 1987 Omnibus Reconciliation Act included a sweeping Nursing Home Reform Act with a provision for residents to be “free from physical or chemical restraints”. However, this reform did not provide for an effective mechanism to enforce this provision.
The FDA imposed a black box warning on the off-label use of antipsychotics in 2008 citing a higher risk of mortality and serious cardiovascular complications for persons living with dementia. Despite this warning the prevalence of antipsychotic use continued and in 2011 it was estimated that 1/3 of all nursing home residents with a diagnosis of dementia were receiving antipsychotic medications.
In 2012, CMS created the National Partnership to Improve Dementia Care in Nursing Homes, in recognition of the high prevalence of concerning antipsychotic drug use. This initiative included state and facility quality programs, increased regulation, and public reporting of antipsychotic use. Data compiled from 2012-2019 revealed a 40% reduction of antipsychotic, antiepileptic, and sedative hypnotic medications. It appeared perhaps that care was improving in facilities.
The COVID-19 pandemic has brought the many inadequacies of our nursing home system to light, among these findings is a resurge of increased use of antipsychotic medications and sub-quality care for those living with dementia. It is further troubling to learn that clinicians are utilizing loopholes and making false diagnosis to continue problematic clinical practices.
Older adults living with dementia in nursing facilities are among our most vulnerable populations. Improvements in practice and quality of care for these individuals is possible through systematic change and resource allocation that addresses policy, quality improvement, and regulation for nursing homes.
Crystal, S., Jarrín, O. F., Rosenthal, M., Hermida, R., & Angell, B. (2020). National partnership to improve dementia care in nursing homes campaign: State and facility strategies, impact, and antipsychotic reduction outcomes. Innovation in Aging, 4(3).
Thomas, K., Gebeloff, R., and Silver-Greenberg, J. (2021, September 11). Phony Diagnoses Hide High Rates of Drugging at Nursing Homes. The New York Times.