With casual summer dwindling and busy autumn looming, the very last place most of us envision ourselves ever inhabiting is the small, foggy world where many nursing home residents today reside: sedated, to a lesser or greater extent, by antipsychotic drugs that impose calm on agitated minds and bodies.
On Tuesday the federal Centers for Medicare and Medicaid Services boasted of a drop in the use of these controversial drugs, which — depending on dosage and other variables — can gently relieve excited symptoms of dementia or leave patients stupefied in a zombielike trance. CMS (with one M), as it’s known, is concerned that antipsychotics are overprescribed for elderly residents of nursing homes, in part because the drugs do make patients who are difficult to handle more compliant.
So when CMS reports a 9 percent decrease in the percentage of patients receiving drugs such as Abilify, Seroquel, Zyprexa and many others, the knee-jerk response is appealing: It has to be good that, between late 2011 and early 2013, the share of nursing home patients on antipsychotics fell from 23.9 percent to 21.7 percent, according to numbers reported Tuesday by The Wall Street Journal. CMS hopes for a steeper decline later this year, to about 20 percent of patients.
But knee-jerk reactions aren’t necessarily right. While a drop in usage of any powerful medicines sounds positive, and here allows the feds to brag of their success, we’re left with a troubling question: Are antipsychotics being less frequently prescribed for difficult but still manageable patients who don’t need them — or less frequently prescribed for disturbed and physically aggressive patients who very much do? In other words, if 30,000 fewer nursing home patients now take these drugs, as the government suggests, are they the appropriate 30,000?
Ask anyone who works in a nursing home: Caring for the elderly can be an unalloyed joy in 19 rooms and a frightful danger in the 20th. Much as the rest of us can’t imagine that our loved ones — and heaven forbid we ourselves — ever would be so distraught that antipsychotics would be appropriate medicine, that just isn’t a real-world truth. Thus some of the drugs commonly and helpfully used to treat schizophrenia, depression, bipolar and other disorders in younger people are prescribed to treat older dementia patients for psychosis or aggression.
It’s those uses in nursing homes that CMS seeks to curb. And it’s true that changes in a patient’s daily care, experiences and environment within a facility can allow for lower dosages, or no antipsychotic meds at all. But that sentence sounds more reasonable in the abstract than it would to nursing home staff members trying frantically to subdue a mentally ill, chronically uncooperative and increasingly physical patient.
Two more complexities in decision-making: Hard-to-handle and perhaps self-destructive patients tend to be the most disenfranchised residents of a nursing home; for lack of dialed-in family members, caregivers and doctors face no objection to sedating the patients and making life simpler (and safer) for everyone. What’s more, patient advocates note that, for reasons not totally understood, elderly patients on substantial doses of some antipsychotics have higher mortality rates; their lethargy may invite or aggravate infections, or something as simple as a diminished ability to cough energetically may leave them vulnerable to serious respiratory ills.
We need to stress that, regardless of what the noisiest patient advocates say, there’s nothing evil about antipsychotics; these drugs, the product of more than 60 years of research, help many people thrive in the general population as well as in nursing homes. But when the setting is wrong, antipsychotics can be too powerful for the task at hand; there’s a reason that, early on, the use of such medication was referred to by medical professionals as a pharmacological lobotomy.
We’re glad CMS is pressing ahead to lower the use of these drugs. But there’s much a government agency cannot do that family members, caregivers, physicians and pharmacology specialists can.
In the best of worlds, those people talk through each case to resolve three questions: Can we manage this patient without antipsychotics? If not, given his or her mental health, physical health and even size, how do we settle on the right drug at the right dosage? And will we monitor this patient, especially until we know we’re getting the ideal effect?
In the worst of worlds, somebody isolates a problem patient. Somebody else writes a prescription. And everyone except an overmedicated and helpless man or woman breathes a sigh of relief.
