Antipsychotic Drug Epidemic Ravaging America’s Nursing Homes

Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare

The U.S. House of Representatives’ Ways and Means Committee released Under-Enforced and Over-Prescribed: The Antipsychotic Drug Epidemic Ravaging America’s Nursing Homes on July 27, 2020.  This is a 53-page report that merits your attention.  These are excerpts from the Executive Summary to whet your interest (bolding added by me):

  • In the fourth quarter of 2019, approximately 20 percent of all skilled nursing facility (SNF) residents in the United States (U.S.) – about 298,650 people every weekreceived some form of antipsychotic medication, most without any psychosis diagnosis for which the drugs are indicated.
  • Nursing homes continue to give these powerful drugs to residents despite the Food and Drug Administration’s (FDA) issuing a black box warning specifically stating that the use of off-label antipsychotics among seniors with dementia can result in injuries, hospitalizations, and even death. In fact, individuals over 70 are 3.5 times more likely than younger individuals to be admitted to the hospital due to adverse drug reactions associated with psychotropic medications.  One recent study found that the inappropriate use of antipsychotic medication was associated with a 50 percent increased risk of a serious fall-related bone fracture.
  • The analysis presented in this report illustrates that, across the nation, antipsychotic citation rates have decreased dramatically since 2017. Nevertheless, use of antipsychotics remains high, particularly in the Northwest and Midwest, and the extent to which nursing home management may have falsified diagnoses to justify the inappropriate use of these drugs as a chemical restraint is relatively unknown. Regulatory roll-back and a lack of meaningful federal enforcement may have also played a significant role in permitting the use of antipsychotics to continue.
  • The high rate of antipsychotics use across our nation’s nursing homes shows that many facilities continue to resort to the use of these potentially dangerous drugs as a chemical restraint – in lieu of proper staffing – which has the potential to harm hundreds of thousands of patients.
  • As the population continues to age and more Baby Boomers increasingly rely on institutional care provided in SNFs, it is critical that meaningful steps are taken to reduce the overuse of antipsychotics and ensure the nation adequately and appropriately addresses the needs of these vulnerable patient groups.

This report provides an overview of antipsychotic citation trends in SNFs from 2015 to 2018. Using data from CMS and the Kaiser Family Foundation (KFF), the Committee conducted five state-level descriptive analyses.

There are 4 Appendices in this report for your review as well as several thought-provoking graphs.

Appendix A … METHODOLOGY AND LIMITATIONS

Appendix B … STATE-LEVEL ANTIPSYCHOTIC CITATION TABLES FOR SKILLED NURSING FACILITIES

Appendix C … CMS ADMINISTRATIVE ACTIONS TO REDUCE OR ELIMINATE NURSING HOME PROTECTIONS

Appendix D … SUMMARIES OF SELECT SKILLED NURSING FACILITIES CITATION FOR UNNECESSARY MEDICATIONS AND RESIDENT HARM (G OR HIGHER LEVEL CITATION), 2017-2018

“Over 40 percent of U.S. nursing homes have what we call chronic deficiencies: repeated violations of the same regulatory requirement year after year after year. Abuse, neglect, even crimes against residents are persistent and pervasive. Approximately 20 percent of residents are administered antipsychotic drugs every day, despite the FDA’s black box warning not to use these drugs on elderly people due to substantial risk of harm and even death.”

Whatever the reason for the changes in antipsychotics prescribing patterns documented in this study, it is reasonable to conclude that the overuse and misuse of antipsychotics is pervasive and continues to occur at unacceptably high rates. Incremental change is just that – incremental – and insufficient for the thousands of families who have entrusted their loved ones to nursing homes only later to face unnecessary hospitalizations or even death.

The NHRA in 1987 was evidence that policymakers, experts, and advocates believed there was a better future possible for nursing home residents – one where human dignity and personalized care trumped all other concerns. The health system’s stagnation in eliminating chemical restraints in nursing homes reflects an inability to realize the goals of Congress more than 30 years ago, when Americans hoped for a better future for the system’s most vulnerable. Today, the stark reality of COVID-19 has brought this fact to the public’s consciousness. As the population continues to age and more Baby Boomers are relying on SNFs for rehabilitation services and long-term care, it is critical that policymakers and regulators continue to address antipsychotic misuse in the nursing home setting and ensure the nation adequately addresses the needs of these vulnerable patient groups. As the Inspector General stated in 2011, Americans should continue to be outraged, and those who rely on nursing homes deserve better.

Please also review QSO-19-07-NH … Enhanced Oversight and Enforcement of Non-Improving Late Adopters issued March 1, 2019.

The enhanced oversight and enforcement approach will focus two subgroups of these late adopter nursing homes which have had a prior history of noncompliance citations with specific federal requirements related to antipsychotic medication use and dementia care. Group one facilities had three or more deficiency citations, while group two had two citations. These two groups were stratified by the number of noncompliance deficiencies cited under unnecessary medications or psychotropic medications – two or more times since January 1, 2016. Given facilities are surveyed on average annually, the January 1, 2016 timeframe allowed for identification of a deficiency noncompliance pattern related to unnecessary medications or psychotropic medications and inclusion of most recent citations.

In addition to the enhanced oversight and enforcement for the two groups consisting of 235 nursing homes, all of late adopter facilities (approximately 1,500) are also encouraged to continue focusing on reducing use of antipsychotic medications and person-centered approaches as CMS will closely monitor progress on the remaining facilities outside of the subgroups.