Study Warns of Drugging in Nursing Homes

Many older Americans living in nursing homes receive excessively potent psychoactive drugs, according to a new study exploring what some experts say is an epidemic of over-medication within the country’s expanding elderly population.

The researchers, at Harvard Medical School, found that mind-altering drugs are being used as “chemical restraints” in short-staffed facilities, and that medication practices have failed to keep up with advances in geriatric medicine.

For example, more than half of the nursing-home residents in the study regularly received psychoactive drugs, such as sedatives and anti-depressants. One quarter received anti-psychotic drugs, even though only 15% had been diagnosed psychotic.

“My concern is that people are having their minds blunted in a way that probably does diminish their capacity to appreciate life,” said Dr. Jerry Avorn, a co-author of the paper published today in the Journal of the American Medical Assn.

The drugs found to be widely used include the anti-depressant amitriptyline, or Elavil, considered undesirable in the elderly because it affects certain nervous system activities and is highly sedating. The researchers said “newer and safer” anti-depressants are preferable; they did not specify which.

Behavior Control

Other drugs widely used were the tranquilizers flurazepam, diazepam and chlordiazepoxide, also known as Dalmane, Valium and Librium. Again, the researchers said newer, shorter-acting drugs in that class are preferable in elderly people.

They also found that anti-psychotic drugs were used to control volatile or aggressive behavior. The researchers said past studies have identified serious side-effects from anti-psychotics in the elderly, and there is no proof that such drugs benefit non-psychotic patients.

Tranquilizers, anti-depressants and anti-psychotics have been linked to a wide range of toxic effects in the elderly, including confusion, over-sedation, constipation, incontinence, restlessness, shaking and difficulty with movement.

“What’s important to recognize is that these subtle forms of impairment, when grafted onto an elderly patient, can have profound and sometimes devastating consequences,” Dr. Gideon Bosker, a specialist in drug-prescribing in the elderly, commented this week.

He cited studies indicating that hip fractures occur frequently when over-medicated patients fall.

The researchers, headed by Dr. Mark Beers, now at UCLA, studied the medical records of 850 residents in 12 Massachusetts nursing homes over one month. The homes, so-called intermediate-care facilities, are believed to be representative of others nationwide.

Intermediate-care facilities, in contrast to skilled nursing facilities, do not necessarily require that licensed nurses care for residents. Officials say a majority of all nursing homes fall into that category. About 1.5 million Americans now live in nursing homes.

In the study, the researchers found that nearly two thirds of the residents had prescriptions for one or more psychoactive medications. Because many of the prescriptions were to be used “as needed,” 53% actually used psychoactive drugs on five or more days during the month studied.

One third of all the patients had orders written for anti-psychotic medications, primarily Haldol. Forty percent of all patients were prescribed sedative/hypnotics, and 28% used them. Fourteen percent used anti-depressants on at least five days.

Especially alarming were the choices of drugs within each class, the researchers said. Repeatedly, they found physicians had prescribed powerful, long-acting drugs where safer, preferable alternatives were available.

“They’re still using the wrong drugs, they’re using them in high doses and they’re using them too frequently,” said Beers, an assistant professor in the division of geriatric medicine at the UCLA School of Medicine.

Beers traced the problem in part to physicians’ failure to keep up with advances in geriatric pharmacology. Avorn, an associate professor at Harvard and Beth Israel Hospital in Boston, also cited “important organizational imperatives in nursing homes that push the system toward the use of psychoactive drugs.”

“Specifically, (there are) increasing numbers of patients with dementing conditions of various kinds, cared for by staffs which are not always large enough to manage them in the one-on-one interpersonal way that might make drugs unnecessary,” Avorn said in an interview.

One nursing-home industry official, however, countered that current standards discourage use of drugs for so-called chemical restraint. She said such practices may help control behavior but they inevitably create new problems.

“I have not seen that as a prevalent approach,” said Vera Reublinger, long-term care nurse specialist with the American Health Care Assn., the trade association for the long-term care industry. “But I can’t speak for the entire industry.”

Avorn and others also emphasized that psychoactive drugs serve an important function for some institutionalized elderly people. “I don’t want to give the impression that in every case, use of these drugs makes them worse,” Avorn said.

To avoid over-medication, experts suggested that friends and family of elderly residents review the patient’s drug list with the physician, especially scrutinizing drugs that affect the central nervous system or have long-acting sedative or hypnotic effects.