Elderly in a Fog of psychotropic drugs in Nursing Homes

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Clearing the Fog in Nursing Homes By PAULA SPAN

The woman, who was in her 90s, had lived for several years at the Ecumen Sunrise

nursing home in Two Harbors, Minn., where the staff had grown accustomed to her

grimaces and wordless cries. She took a potent cocktail of three psychotropic

drugs: Ativan for anxiety and the antipsychotic Risperdal to calm her, plus an

antidepressant. In all the time she'd lived at Sunrise, she hadn't spoken. It

wasn't clear whether she could recognize her children when they came to visit.

The Two Harbors home happened to be where Ecumen, which operates 16 nonprofit

Minnesota nursing homes, was preparing an experiment to see if behavioral rather

than pharmacological approaches could help wean residents off antipsychotic

medications. They called it the Awakenings program.

" What's people's biggest fear? Being a `zombie' in a nursing home, " said Laurel

Baxter, the Awakenings project manager.

Any visitor can see what she means. Even in quality nursing homes, some

residents sit impassively in wheelchairs or nod off in front of televisions,

apparently unable to interact with others or to summon much interest in their

lives. Nursing home reformers and regulators have long believed that this

disengagement results in part from the overuse of psychotropic medication to

quell the troublesome behaviors that can accompany dementia — yelling,

wandering, aggression, resisting care. For nearly 25 years, federal law has

required that psychotropic drugs (which critics call " chemical restraints " ) be

used only when necessary to ensure the safety of a resident or those around her.

The drugs can cause serious side effects. Since 2008, the Food and Drug

Administration has required a so-called black box warnings on their packaging,

cautioning that they pose an increased mortality risk for elderly patients.

Nevertheless, a national survey reported that in 2004 about a quarter of nursing

home residents were receiving antipsychotic drugs. (Among the antipsychotic

drugs most commonly used in nursing homes are Risperdal, Seroquel and Zyprexa.)

Though they may be prescribed less frequently following the F.D.A.'s warnings,

these drugs are still overused in long-term care, said Dr. Mark Lachs, chief of

geriatrics at Weill Cornell Medical College. And once the pills are prescribed,

residents keep taking them. " They get perpetualized, like insulin, " he told me,

even though the behaviors they're meant to soothe may wane anyway as dementia

progresses.

" If a place is understaffed, if it takes particularly unruly patients, you can

see how it happens, " Dr. Lachs added. " Behavioral interventions are far more

time-consuming than giving a pill. "

Nevertheless, Ecumen's Awakenings project emphasizes nondrug responses.

" Medications have a place, but that shouldn't be the first thing you try, " said

Eva Lanigan, director of nursing at the Two Harbors facility.

So the home trained its entire staff (housekeepers, cooks, dining room servers,

everyone) in a variety of tools to calm and reassure its 55 residents: exercise,

activities, music, massage, aromatherapy. It taught people the kind of

conversation known as " redirecting " — listening to elders and responding to them

without insisting on facts that those with dementia can't absorb or won't

recall.

" The hands-on, caring part is the most important, " Ms. Lanigan said. " Sometimes,

people just want a hug. You sit and hold their hand. "

At the same time, consulting with a geriatric psychiatrist and a pharmacist, the

home began gradually reducing the doses of antipsychotics and antidepressants

for patients whose families agreed. Among them: the woman with the mysterious

cries.

As Dr. Lachs pointed out, behavioral interventions are labor-intensive. Two

Harbors hired an additional nurse to oversee those efforts, and Ms. Lanigan was

available to answer staff questions around the clock. Ecumen estimates that

introducing the program to a 60-bed nursing home cost an additional $75,000 a

year for two full-time employees.

The results startled even the believers, however. Every resident on

antipsychotics (about 10) was able to stop taking them, and 30 to 50 percent of

those taking antidepressants also did well without them. When drugs still seemed

necessary, " we tried to reduce them to the lowest dose possible, " Ms. Lanigan

said.

Encouraged, Ecumen has introduced the Awakenings program to its 15 other nursing

homes, using a $3.8 million, three-year grant from the state of Minnesota. " I

believe we may learn that spending a little time now with a resident, preventing

the use of psychiatric medications and their side effects, you'll save time and

money in the long run, " said Ms. Baxter, the project manager. " I'm optimistic. "

Of course, you can't tell how well nondrug approaches work based on one

facility's outcomes. " We know how to reduce behavior problems and mood issues in

controlled clinical trials, " said Van Haitsma, a senior research

scientist at the Polisher Research Institute in Philadelphia. " The actual nuts

and bolts of how do you do this and keep it in place — over not weeks or months,

but years — is a question the field is struggling with. " Turnover among both

staff and residents is high in nursing homes, she pointed out.

But with reduced medications, the woman at the Two Harbors home did seem to

awaken. She was able to speak — haltingly and not always understandably, but

enough to communicate. And what she let Ms. Lanigan know, after years of being

virtually nonverbal, was that she was suffering physical pain, the cause of her

crying out.

It took doctors a while to find effective medications for her nerve condition,

but they were eventually able to make her more comfortable without further

fogging her mind. She stopped taking psychotropic drugs altogether.

None of this can halt dementia; it's a terminal disease, and it took this

resident's life last year. But in her final months, she smiled and played

balloon volleyball with other residents and could say she felt fine or was

hungry.

" She engaged more. Her family came to help her eat, " Ms. Lanigan said. " It was a

big change. "

http://newoldage.blogs.nytimes.com/2011/02/15/clearing-the-fog-in-nursing-homes/