Antipsychotic Use for Elderly Nursing Home Residents: OIG Report

There have been some recent reports about the increasing use of atypical antipsychotics on both ends of the age spectrum. The US GAO (Government Accountability Office) issued a report in December finding higher rates of psychotropic use, including antipsychotics, in foster children compared to nonfoster children (3-4 times higher). Recommendations for increased vigilance and monitoring were made.

In May 2011, the US OIG (Office of the Inspector General) issued a report entitled, "Medicare Atypical Antipsychotic Drug Claims for Elderly Nursing Home Residents." This report examined claims from a six-month period in 2007, finding that 14% of nursing home residents had at least one claim for an antipsychotic, amounting to over $300 billion. Eighty-three percent of these claims were for off-label conditions (e.g., agitation, insomnia), and 88% were associated with a dementia diagnosis. Atypical antipsychotics carry a warning about using them in elderly patients with dementia due to an increased risk of heart attack and stroke.

So, there was a hearing in November before the Senate Special Committee on Aging about this issue. The hearing itself can be viewed on their website, as well as links to the testimony provided.

This is an important issue, because as our population ages and develops more dementia, the pressure to manage the resulting behavioral problems with pills rather than with patience, understanding, and adaptation. Medications can have a role, but cannot be the only solution and should not be used excessively. Some quotes follow.

I believe that behavior itself is not a disease. Simply put, behavior is communication. In people whose ability to communicate with words is limited (such as patients with dementia), communication tends to be more nonverbal (i.e. behavioral). Our challenge is to figure out what they are trying to say, and if they are in distress, to identify the underlying causes and precipitants. Many of the behaviors that are commonly observed in patients with dementia and that are often labeled as difficult, challenging, or bad, such as agitation, wandering, yelling, inappropriate urination, and hitting are typically reactive, almost reflexive behaviors that occur in response to a perceived threat or other misunderstanding among patients who by the definition of their underlying illness have an impaired ability to understand. ...

Patients with dementia often have trouble comprehending their environment, resulting in misperceptions that are often perceived as threats. In most instances, the key to behavior management in dementia is environmental modification, especially the human environment, which may be as simple as changing our approach and our response in order to prevent and minimize distress.  The fundamental basis of health care is caring for others. The fundamental basis of caring is love, acceptance, and respect for persons.

~Jonathan M. Evans, MD, MPH, FACP, CMD
Vice President, AMDA−Dedicated to Long Term Care Medicine

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Medications are used often as the first intervention because family members, care givers, nurses and doctors in ALL settings lack information or training regarding alternatives.  To merely target this one class of drug as the “problem to be fixed” will have the unintended consequence of increasing the use of other, equally risky medications, such as benzodiazepines, anti‐seizure medications and sedative‐hypnotics, all of which have side effects that include confusion, falls, and risk of death.  Furthermore, if the focus is only on the nursing home, we will create barriers to access for care that patients and families desperately need.  In some states, such as California where consent rules regarding the use of any psychoactive medications in nursing homes are in place, some nursing homes have declined admissions because of a “history of behavior problems requiring psych meds”, creating real challenges for caregivers and often requiring patients to stay for long periods in the acute care hospital. The solution to this challenge is not a short‐term fix, but rather a two‐fold strategy that involves systemic application of non‐pharmacological behavioral interventions as the first line of treatment, with close monitoring for appropriate and limited use of medications when the non‐pharmacological approaches have not worked.

~Cheryl Phillips, M.D., AGSF
Senior VP Advocacy, LeadingAge

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Despite the severity and frequency of these symptoms, there is currently no FDA approved therapy used to treat BPSD [behavioral and psychotic symptoms of dementia]. As a result, many types of medications, including atypical antipsychotics, have been used “off-label” in an attempt to mitigate these symptoms. In 2005, the FDA examined this issue and found that the use of atypical antipsychotics in people with dementia over 12 weeks helped to reduce aggression, but was also associated with increased mortality. ...

The Association recommends training and education on psychosocial interventions for all professional caregivers. Specifically, the Alzheimer’s Association believes “in making the decision to utilize antipsychotic therapy the following should be considered:

 Identify and remove triggers for behavioral and psychotic symptoms of dementia: pain,
under/over stimulation, disruption of routine, infection, change in caregiver, etc;

 Initiate non-pharmacologic alternatives as first-line therapy for control of behaviors;

 Assess severity and consequences of BPSD. Less-severe behaviors with limited
consequences of harm to individual or caregiver are appropriate for non-pharmacologic
therapy, not antipsychotic therapy. However, more severe or “high risk” behaviors such
as frightening hallucinations, delusions or hitting may require addition of antipsychotic
trial;

 Determine overall risk to self or others of BPSD, and discuss with doctor the risks and
benefits with and without antipsychotics. Some behaviors may be so frequent and
escalating that they result in harm to the person with dementia and caregiver that will in
essence limit the life-expectancy and or quality of life of the person with Alzheimer’s
disease; and

 Accept that this is a short-term intervention that must be regularly re-evaluated with your
health care professional for appropriate time of cessation.”

~Tom Hlavacek
Executive Director, Alzheimer’s Association of Southeast Wisconsin

The Reversible Causes of Dementia

I'm writing this post because the New York Times has been writing about how thyroid disorders and Vitamin B12 deficiency can be responsible for neuropsychiatric symptoms. 
Read the article about Vitamin B12 here.
Read the article about Thyroid function here.  

This is news?  When I was in medical school, the knee jerk response to memory complaints was to order labs to rule out the reversible causes of dementia: CBC, Chemistry panel, VDRL (syphilis), thyroid function tests, folate and B12 levels, urinalysis, and then perhaps a brain CT.

So let me tell you how a physician thinks about dementia.  First let me tell you what dementia is: the decline in cognitive function from a prior baseline, often seen by the patient as memory problems, beyond what would be expected with normal aging. 


A patient presents with complaints of memory problems.  The physician (usually an internist or primary care doc) takes a history: when did this start, did anything precede it, are things stable or getting worse?  What exactly is happening and is the patient actually having memory problems?  Sometimes people think they are having memory problems, but really what is happening is that they are anxious or distracted, so the information never makes it into their brain to be retrieved or remembered later.  "I told my husband to take out the trash during the Super Bowl and he didn't remember to do it."  A quick measurement of memory may be done, such as the Mini-Mental Status Exam, which tests a variety of components of cognition such as orientation, the ability to immediately recall, memory, concentration, the ability to follow directions, and the ability to copy a diagram, write a sentence, and follow a written command.  It's a simple test, and most people get perfect scores, and it's a quick way to follow progress over time.   A physical exam is done, including a neuro exam, and if there are focal findings --like the absence of reflexes or weakness, or loss of sensation, or a history of loss of consciousness, seizures, or a head injury-- these are noted. 


The only way to be 100% certain of the type of dementia is to biopsy the brain.  We don't generally do that.  Instead, we rule out the "reversible" causes of cognitive decline-- infections, thyroid disorders, neurosyphilis, folate orVitamin B12 deficiency, or metabolic problems such as confusion with markedly elevated blood glucose or neuropsychiatric symptoms with hyperparathyroidism.  Some of these illnesses are discovered with blood tests, others require a scan to look for anatomical lesions, like hydrocephalus, stroke, subdural hematoma.  If a reversible cause of dementia is found, it can be treated and it will often get better. Oh, and I should add that Major Depression can mimic mild dementia, and this too can be treated, it's called pseudo-dementia and when the depression gets better, the dementia gets better.


If a patient has dementia, and the reversible causes are ruled out, then the diagnosis of depression is based on the features of the disorder and the course it takes.  Alzheimers' disease is the most common type of dementia, and it has a progressive course with some predictability.  Patients with Alzheimer's disease will have a good recall for past events, but they may forget more recent events.  Personality and social appropriateness are preserved until well into the illness, and the early stages are often rather subtle.  Decline can take place over a few years or many years, but the course is always progressive. Medicines, such as Namenda or Aricept may be prescribed in the hopes of slowing the course, and patients with vascular dementia may be told to take aspirin to prevent future episodes.  While patients have good days and bad days, these illnesses do not remit.

Vascular dementias progress in a more step-wise course.  Patients will have a sudden onset of impairment, but things stay at that level for a while, until another event happens and there is another sudden decline. The course is less predictable with regard to what faculties are compromised when.  Some patients have both forms of dementia, or a mixed etiology. 

Other forms of dementia include Pick's disease (fronto-temporal dementia), Lewy Body dementia, and dementias associated with Huntington's Disease, Parkinson's Disease, and HIV, and dementia due to repeated brain trauma.

Okay, this is my quicky discussion of  dementia.  Please don't use this as a comprehensive resource, it's mostly off the top of my head.  Roy can pipe in with all the things I missed, I'm sure there are plenty.

Daniel Carlat on Antipsychotic Medications for Agitation in Patients with Dementia

Lately, it seems like all the press about psychiatry in The New York Times is bad. We don't talk to our patients, we over-medicate them all from the children to the elderly, we all get bribes from drug companies. It's not that I don't think that these things don't happen, it's just that I don't like the sensational tones, and the one-sided nature of the presentation of healthys as bad, the generalizations that it's "everyone," and the use of information taken out of context to make our practitioners look bad.

In a May 9th article Gardiner Harris writes:

More than half of the antipsychotics paid for by the federal Medicare program in the first half of 2007 were “erroneous,” the audit found, costing the program $116 million for those six months.

“Government, taxpayers, nursing home residents as well as their families and caregivers should be outraged and seek solutions,” Daniel R. Levinson, inspector general of the Department of Health and Human Services, wrote in announcing the audit results.

Mr. Levinson apparently feels the government should collect information on diagnoses so correct prescribing can be assessed.

On CNN today, Danny Carlat writes his own response in "In Defense of Antipsychotic Drugs for Dementia."

The story highlights include:

STORY HIGHLIGHTS

• Daniel Carlat: Report implies evil doctors are giving deadly drugs to nursing home patients
• But antipsychotics are most effective drug for calming agitation in dementia, he writes
• Carlat: No drugs are FDA-approved for this agitation, a terrible condition

Carlat writes:

But in this particular case, the Office of the Inspector General has it wrong, and Levinson's statements on behalf of Health and Human Services reflect an astonishingly poor understanding of the workings of medical care in general and psychiatric care in particular.

The unfortunate fact is that no medications are FDA-approved for the agitation of dementia, and yet the condition is common.

Although it's true that a prescription for antipsychotics to treat agitation in dementia is "off-label," this hardly means they are ineffective or that Medicare claims for these drugs are "erroneous." In fact, large placebo-controlled trials have shown that antipsychotics are the most effective medications for the agitation that often bedevils patients with dementia.

When these drugs are successful, they soothe the inner turmoil that makes life intolerable for these patients, improving their quality of life dramatically.

Suicide, Brains, and Football

In yesterday's New York Times, Alan Schwarz wrote about the tragic suicide of football player Dave Duerson this past week. Schwarz notes that prior to shooting himself, Duerson texted family members that he wanted his brain examined for Chronic Traumatic Encephalopathy, a condition we've discussed before in our post Brains, Behavior, and Football.

Schwarz writes:

Doctors, N.F.L. officials and even many players denied or discredited the links between football and such brain damage for months or even years. The roughly 20 cases of C.T.E. that have been identified by groups at Boston University and West Virginia University were almost always men who had died — most with significant emotional or cognitive problems — with no knowledge of the disease. Now, for the first time he knows of, Stern said, a former player has killed himself with the specific request that his brain be examined.

I'm left to wonder, did this former football player have this problem? Sometimes depression alone causes memory problems and sometimes people with depression worry that they have Alzheimer's disease, or any number of other illnesses for that matter. Treating the depression may help the memory problems, and may alleviate the fears of other illnesses. And we don't know much about the Chronic Traumatic Encephelopathy induced by repeated head injuries: is the course of the dementia altered by early intervention with medications? Does the depression respond to the usual treatments for mood disorders? Could Mr. Duerson have been saved, at least for a while?

Here's an article on the treatment of chronic brain injury with hyperbaric oxygen in animal models:
http://www.hbot.com/first-successful-treatment-of-chronic-traumatic-brain-injury

And here's an emedicine article on treatments for repetitive brain injuries (not necessarily specific to CTE) with medicine recommendations, but no mention of antidepressants or medicines to slow the course of dementia:
http://emedicine.medscape.com/article/92189-treatment

Here's a medscape article on CTE and dementia:
http://www.alzheimersreadingroom.com/2010/08/causes-of-dementia-chronic-traumatic.html

And, finally, here's a shout out to my friend and med school classmate Robert Morrison, M.D., Ph.D. whose paper for our public health class was published in JAMA back in 1986 as a state of the art review of boxing and brain injury: http://jama.ama-assn.org/content/255/18/2475.short

Is it worth it in the name of sports?

Could I ask a huge favor of the next football player who considers suicide? Instead of completing the act, could you have your depression treated and then write about the results? It would be an enormous contribution. Sure, it would be an anecdote, and not a controlled trial, but perhaps it would add something to the field. And we'd be happy to publish your story here on Shrink Rap.

My heart goes out to the family of Dave Duerson.