The PDF in which this article appears can be found in Bifocal Vol. 44 Issue 3.
According to Human Rights Watch, in an average week, “179,000 residents of long-term nursing homes across the country are given antipsychotic drugs…that are not appropriate for their condition” (Lardieri, 2018). Doctors administer a lot of prescriptions for medications that are meant to help patients. There are a vast number of medications that are often used to treat different problems that we experience. A relatively small percentage of adults, about 1.6 % according to the NIH, are prescribed “antipsychotic medication” (Dennis et al., 2020). However, the Department of Health and Human Services’ Office of Inspector General found that in 2007, 14 percent of nursing home residents receiving Medicare benefits had claims for using an antipsychotic medication, and 83 percent of these claims were for off-label use of such medications, or for use for which there was no clinical indication” (Introcaso, 2018).
Responsible Use of Antipsychotic Medications
Antipsychotic medications are intended to be prescribed to people to help “manage mental health phenomenon known as psychosis” and typically are given to those suffering from schizophrenia and bipolar disorder (Todd, 2018). Antipsychotic medications have been empirically found to have dangerous side effects in middle age and older adults and can be more lethal in those living with dementia. The Federal Drug Administration (FDA) has given antipsychotic medications a black box warning to “increase the prominence of warning to the ‘learned intermediary’ or the physician…” (Upham, 2018). However, these medications can often be found in nursing home facilities to care for the elderly. The issue at hand is the dangerous and improper use of antipsychotic medication by middle-aged or older adults in skilled nursing homes, which can lead to an increase in mortality rate, movement disorders, motor side effects, strokes, and many other impairments.
Initially, antipsychotic medications were thought to provide “safe and effective” treatments for older adults dealing with psychotic disorders. However, this is no longer the case. From recent scientific observations, we are discovering new harmful side effects that stigmatize the notion that antipsychotic medications are more harmful than good when used to treat middle-aged or older adults. In one study, scientists “compared the safety and effectiveness of the four most commonly prescribed atypical antipsychotics (aripiprazole, olanzapine, quetiapine, and risperidone) in a group of 332 outpatients over the age of 40 years, with psychotic symptoms related to schizophrenia, mood disorders, PTSD, or dementia, over 2 years or treatment.” Throughout the experiment, over half the participants left due to side effects and lack of efficacy. The research concluded that “the rates of serious adverse events such as hospitalizations, deaths, and emergency room visits for life-threatening conditions were also high (23.7%) as were the rates of non-serious adverse events (50.8%) (Jeste and Maglione, 2015).”
Barriers to Proper Use of Antipsychotic Medications
Results of the study suggested that atypical antipsychotic medication was neither safe nor effective for middle-aged or older adults. The data from this study helped bring awareness to the dangers of antipsychotic medications, however, such medications are still improperly used in nursing homes today. Deriving information from the National Partnership to Improve Dementia Care in Nursing Homes’ “Antipsychotic Medication Use Data Report” (April 2022), antipsychotic medication usage has gone down about 8% in the past decade (from 2011-2021), but it has hit another plateau at about 15% from around 23%. If we do not continue to decrease the use of antipsychotic medications on older adults who do not need them, the aging population will continue to be hospitalized or die when the resources are there to prevent this from happening.
Questions often arise about how antipsychotic medications are used in nursing homes. If we know these medications are harmful to middle age and older adults, especially those with specific cognitive conditions like dementia, why are they continuously being used in nursing homes? Nursing homes sometimes use these medications to sedate their residents (Introcaso, 2018). Due to nursing homes being understaffed, the distribution of antipsychotic medication acts as a convenience for the staff rather than helping the residents. Reports from Human Rights Watch (HRW) have found that these medications are “frequently administered without the residents, or their families, or surrogates, free and informed consent or…without their awareness.” HRW also estimated that on an average week, “nursing homes administer antipsychotic drugs to more than 179,000 residents who do not have a diagnosis for which antipsychotic medications are approved.” Such residents have a higher risk of receiving unwanted side effects, being hospitalized, and an increased mortality rate.
There is legislation designed to primarily negate the use of antipsychotic medications in older adults, but such statutes have had little impact on the use of antipsychotic medications in nursing homes. Medications like Haldol, used to treat schizophrenia and control motor and speech tics for people with Tourette’s syndrome, are still administered to aging residents, luckily not as much as in previous years (Antipsychotic Medication Data User Report). The Department of Health and Human Services’ Office of Inspector General found that in 2007, 14 percent of nursing home residents receiving Medicare benefits had claims for using an antipsychotic medication, and 83 percent of these claims were for off-label use of such medications, or for use for which there was no clinical indication” (Introcaso, 2018).
The misuse of antipsychotic medication has led to the filing of civil lawsuits against the manufacturers of such medications. In 2012, Johnson & Johnson was ordered to pay the federal government $180 million “in a consumer fraud settlement case after it marketed Risperdal to patients with dementia” (Pintas & Mullins, 2020). Risperdal is an antipsychotic medication used to treat patients with schizophrenia. Research shows that the medication should not be used by people living with dementia. Risperdal has harmful side effects such as diabetes, strokes, and hyperglycemia. When used in nursing homes, it was given to patients with dementia, often without informed consent, mainly to calm erratic behaviors. One example of this is Joanna Sienkiewics, a 94-year-old resident at Windsor Gardens of Fullerton, who was prescribed “15 milligrams of the antipsychotic Abilify per day for ‘agitation and resisting care.’” Abilify is different from Risperdal but is still considered an antipsychotic medicine. Her family claimed that they never gave their consent to the facility to give her the drug and believed that it was given to keep her from acting out (Pintas and Mullins, 2020).
The prevalence of antipsychotic use among U.S. adults was 1.6% (n = 320). Over 90% of individuals taking antipsychotics reported having health insurance and a usual place for care, significantly more than their counterparts not taking antipsychotics. Further, those taking antipsychotics reported a higher prevalence of comorbid chronic diseases and took an average of 2.3 prescription medications more than individuals not taking antipsychotics. Individuals taking antipsychotics were more likely to sleep 9 or more hours per night, be a current smoker, and have a body mass index greater than 30 kg/m2 (Dennis et al., 2020).
Steps to Restrict the Misuse of Antipsychotic Medications
Some steps can be taken to restrict the misuse of antipsychotics in older adults. Legislation is needed to limit the off-label use of drugs. Drug manufacturers need to be held accountable for marketing drugs for uses that are known to be dangerous. Nursing facility staff need training and sufficient staffing to manage behaviors without resorting to drugging patients (chemical restraints should only be used when essential to protect the health and safety of the patient.) A system for tracking informed consent on antipsychotic medications needs to be created and followed, as there are ongoing reports of a lack of informed consent by the patient or another person authorized to consent to health care.
The misuse of antipsychotic medications on older adults has been shown to cause detrimental effects on their health, safety, and well-being, especially for individuals suffering from cognitive impairment. If we act upon these issues effectively, we can improve the quality of life for all older adults and rebuild trust in nursing homes. Taking action in reducing the improper use of antipsychotic medications and training nursing home staff on how to care for residents of different groups ensures the safety of today’s older adults and future generations.
- Antipsychotic use data report - centers for Medicare & Medicaid Services. (n.d.). Retrieved September 27, 2022, from https://edit.cms.gov/files/document/antipsychotic-medication-use-data-report-2021q4-updated-07292022.pdf
- Baker, T., & Coleman. (2021, April 19). Oklahoma HB1877: 2021: Regular session. LegiScan. Retrieved December 9, 2022, from https://legiscan.com/OK/text/HB1877/2021
- Dennis, J. A., Gittner, L. S., Payne, J. D., & Nugent, K. (2020, October 1). Characteristics of U.S. adults taking prescription antipsychotic medications, National Health and Nutrition Examination Survey 2013-2018. BMC psychiatry. Retrieved December 9, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7528276/
- Denny-Brown, Noelle, et al. (2020, October 18). Covid-19 Intensifies Nursing Home Workforce Challenges. ASPE. Retrieved October 23, 2022, from https://aspe.hhs.gov/reports/covid-19-intensifies-nursing-home-workforce-challenges-0.
- Hennessey_admin. (2022, March 28). Overuse of antipsychotic drugs threatens lives of elderly. Pintas & Mullins Law Firm. Retrieved October 16, 2022, from https://www.pintas.com/blog/overuse-of-antipsychotic-drugs-threatens-lives-of-elderly/
- Introcaso, D. (2018, April 27). The never-ending misuse of antipsychotics in nursing homes. Health Affairs Forefront. Retrieved October 18, 2022, from https://www.healthaffairs.org/do/10.1377/forefront.20180424.962541/
- Jeste, D. V., & Maglione, J. E. (2013, July). Atypical antipsychotics for older adults: Are they safe and effective as we once thought? Journal of comparative effectiveness research. Retrieved October 11, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4418474/
- Lardieri, A. (2018, February 5). Human rights watch finds nursing homes overmedicate dementia patients. US News. Retrieved December 9, 2022, from https://www.usnews.com/news/health-care-news/articles/2018-02-05/human-rights-watch-finds-nursing-homes-overmedicate-dementia-patients
- Todd, C. L. (2018, December 7). 9 things you should know about taking an antipsychotic. SELF. Retrieved October 13, 2022, from https://www.self.com/story/antipsychotic-drug-facts
- Upham, B., Rauf, D., Lee, K., & Upham, B. (2018, June 28). Understanding the FDA’s black box warnings on drug labels. EverydayHealth.com. Retrieved October 15, 2022, from https://www.everydayhealth.com/fda/what-black-box-warning-drug/