Is the Nursing Home Overmedicating Your Elderly Loved One?

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In the days before nursing homes became so highly regulated, many facilities used medications to chemically sedate their residents. Elders who were calm and slept a lot were easier to manage and required less attention from staff members. Therefore, many homes considered drugging patients to be both efficient and cost effective.

Anti-psychotics and sedatives were frequently prescribed to calm patients, especially those who had Alzheimer’s disease or other forms of dementia. In some cases, a low dose may have been beneficial for residents and staff alike, but these medications are very powerful. They can affect seniors and dementia patients differently compared to the general population, and some even carry black box warnings, indicating that adverse reactions may cause injury or death.

Over the past few decades, nursing homes came under more intense scrutiny regarding safety. Most states, along with the Centers for Medicare and Medicaid Services (CMS) put strict guidelines in place to govern hygiene practices, the use of restraints and, of course, administration of medications. While nursing home regulations have come a long way, the past practice of chemical sedation continues to tarnish the industry’s reputation and factor into families’ decisions regarding long-term care.

There are still many states where these rules aren’t strong enough or well enforced. Talk to any group of people with loved ones in nursing homes and you are bound to find a few who feel that too much medication is given. They may be right. However, my experience with these facilities was quite the opposite.

A Caregiver’s Experience with Medications in Nursing Homes

Several of my elderly family members lived out their final years in a nursing home just two blocks from my house. Throughout the 15 years that I had loved ones in this facility, rarely did I ever have a medication complaint. Whenever there was a change, I was notified. The reason for the regimen change was discussed, and I was free to ask questions and make suggestions.

When I did have a complaint, however, it was because it was too difficult to initiate a change. The same rules and regulations that ensure patient safety and freedom from sedation also create lots of red tape to cut through when a drug truly needs to be added. My father had dementia and experienced severe panic attacks at times. Unfortunately, it was hard for the nursing home staff to get their hands on an “as needed” prescription for managing his anxiety because the prescribing physician didn’t let them keep enough of it on hand at the facility. Of course, Dad’s worst episodes usually happened on weekends when the doctor wasn’t available—Murphy’s Law in action.

Dad didn’t take this medication regularly, so getting it on short notice was often a nightmare. Those weekends of Dad in hell and the staff and me railing against the system trying to get him this drug still live on in my brain. This was definitely a case where an excellent facility should have had more say over how much of a prescription needed to be kept on hand for the benefit of a resident.

The flip side of my story comes from a friend of mine whose father was living in another nursing home in our town. This facility also had a very good reputation, but I’d heard a few more grumbles from families about overmedicating residents. My friend felt his dad was being given unnecessary antipsychotics, even though his father was living in a memory care unit where staff should have been able to handle his symptoms and dementia-related behaviors with non-pharmaceutical options. Eventually my friend moved his dad to a different facility in a neighboring town, and he and his family were happier with the care there.

Each facility follows different state regulations, and some also abide by CMS rules. The staff and internal protocols can vary greatly, so it is crucial for family members to be regularly involved in a loved one’s care to ensure they are being treated fairly and getting the attention they deserve.

How to Determine if the Nursing Home Has Made Medication Changes

Family members often suspect changes to a senior’s medication regimen when they notice changes in their behavior. This includes sleeping more, increased confusion or grogginess, and lethargy. These are concerning changes to get to the bottom of regardless of whether prescriptions are to blame.

Lynn Harrelson, registered pharmacist and owner/president of Senior Pharmacy Solutions Medication Therapy Management Services based in Louisville, Kentucky, encourages family members to immediately address these changes with the appropriate staff. “Ask for the nursing station supervisor and inquire as to any changes in the senior’s status and medications in the last 24 to 48 hours,” Harrelson urges. “Accept explanations of these changes only if they are clearly documented in your loved one’s clinical record, aka their chart.”

Regardless of whether you find these changes noted in the chart, it’s important to discuss your concerns with the director of nursing and your loved one’s physician. “Family caregivers should request that future changes in health status and medication be reported to you or others in your family as part of the senior’s overall plan of care,” says Harrelson. This includes the addition of new medications, even if they are given on an “as needed” basis. Harrelson also recommends that caregivers keep a log of these discussions and any new information they receive when speaking to the nursing staff. This log can be easily referenced at a later date.

It’s important to understand that changes in medical status can also occur as a result of new ailments, like infections, or indicate the progression of an existing chronic condition, like dementia. Verifying the amount of fluid that is being consumed, the amount of food consumed, and any changes in mobility, distance walked, bathroom habits, digestive issues, falls, and possible physical interaction with another resident can be helpful in ruling out underlying causes.

The Argument for Medicating Responsibly

The old practice of overmedicating just to keep seniors manageable is, in my opinion, dead wrong. Still, I think if someone is in physical or mental pain and other alternatives have been exhausted, medication that helps a patient feel calmer or more comfortable should be prescribed.

Antipsychotics have come under fire lately as being ineffective for people with Alzheimer’s disease, but as soon as one study comes out decrying these drugs, another appears soon after contradicting the previous results. I suggest that family caregivers find a doctor they trust who knows their patients well and is able to carefully weigh the risks, benefits and interactions of every medication they prescribe. We can leave the researchers to duke it out at their leisure.

To me, human interaction is crucial for problem-solving in elder care. Hands-on care and an attempt to find out what is bothering a senior should be always be the first resort. Agitation, anxiety and troublesome dementia behaviors can be caused by basic needs like thirst, hunger, being too cold or too hot, and the need to use the restroom or be free of soiled clothing. Staff should be trained to identify and address these needs and offer redirection and gentle reassurance. If it turns out that the person clearly needs a medication to feel better and improve their quality of life, even if only temporarily, why shouldn’t they have it?

Managing medications for elders certainly isn’t a walk in the park. Even drugs that worked for a while can suddenly cause new side effects or interact with other prescriptions. Dosages are tricky in the elderly and allergies are also a concern. But, this is why we entrust a medical facility with our loved ones’ ongoing care. The staff should have the education, training and resources needed to observe their residents and meet their medical and personal needs. This is why conducting careful research and taking tours is crucial when selecting a senior living community. In many cases, there is some trial and error involved, but you’ll want to know that you at least did your due diligence.

Caregiving doesn’t stop after placement, either. It’s important to be alert to a senior’s condition regardless of where they live or what their medical issues are. Family caregivers know their loved ones best and often have a knack for pin-pointing what is causing anxiety or discomfort. Sharing this knowledge with staff members can be extremely helpful for everyone involved.

However, if you suspect a loved one’s long-term care facility is still relying too heavily on medications to pacify patients, even after discussing this matter with the administration, consider bringing it to the attention of the nursing home regulatory body in your state. It may also be wise to consider moving your loved one to a different facility.

Carol Bradley Bursack

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Over the span of two decades, author, columnist, consultant and speaker Carol Bradley Bursack cared for a neighbor and six elderly family members. Her experiences inspired her to pen, "Minding Our Elders: Caregivers Share Their Personal Stories," a portable support group book for caregivers.

Minding Our Elders

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35 Comments

Speaking from personal experience about my mother, who has Parkinson's Disease and, a few months ago, required in-patient rehabilitation for three weeks at a nursing facility following unrelated surgery subsequent to a fall, even reputable nursing facilities drug patients to subdue them merely for the convenience of their own nursing staff. My mother was not an unruly patient; she merely insisted on being given her PD medications at the required times (as did we when we were there with her) and required assistance with going to the bathroom and with picking something up off the floor that she may have dropped when my father and I were no longer visiting her.

Although we stayed by my mother's side for 10+ hours per day during the first week, I had to return to my city and my father had to shorten his visiting hours so as to have time to prepare the house for my mother's return. Therefore, neither my father or I were at my mother's bedside in the evenings. However, when I called to say good night between 7:30 and 8:00 p.m. each night, my mother sounded utterly drugged; she was confused, incoherent, and totally groggy. The nurses assured us that this was common for patients new to a facility environment, etc., but I didn't believe it. My mother was unaware of being given any additional drugs but the ones she normally took for PD at 7:00 p.m. plus the pain pill, but it was just too odd that my mother would be such a different person shortly after 7:00 p.m. each night during those remaining two weeks during her hospital stay. Something that was a "red flag" for me was what my father told me about a conversation that my mother had had with one of the night nurses, namely, that during a conversation that my mother had with that nurse about her PD medications, the nurse disagreed with my mother, stating that she (the nurse) knew better than the doctor. Anyway, I was there for my mother's return home and, from that evening on, she never again exhibited such signs of having been drugged. That's when we knew that our suspicion had been accurate. To our frustration, there is little we could do since, as so often happens in nursing facility situations, we have no proof. The only thing that is doable is to not only not return there but also to spread the word among friends and acquaintances so that others know what we wish we had known in time.

I'll go one step further than Carol Bradley Bursack did when she said, "The old practice of over-medicating just to keep people 'manageable' so that they didn’t need so much staff attention is, in my opinion, dead wrong." and say that it is ILLEGAL to dispense unprescribed medication and ethically and morally wrong to dispense any medications to a conscious and alert patient without the patient's consent.
My mother is not in a nursing home. She lives with me and my husband. She has Alzheimer's disease and she gets very combative and hard to deal with at times. If I didn't have the anti-psychotic drugs to help her, I couldn't keep her with me, so how could I expect a nursing home to deal with her without that help. Often when people put their folks in a home, they don't realize how difficult things can become, because they haven't had to deal with it one on one. Without the help of these drugs, everyone would be upset and out of sorts, including the patient. I would much rather have her a little sedated than so upset and agitated. Dealing with that situation is not good for anyone.
Good article, thank you, Carol.

It reminds me of the time my Dad was in a nursing home.. with last stages of Alzheimer's - dreaded place to be. The family was leery of the drug issue.. it seems my Dad was more distant each day. We also leery of other "staff behaviors" so we all pitched in and visited Dad every day. My sisters did most of the work during the week and I helped out on weekends... we were there everyday for lunches and dinners and of course breakfast too when we could make it. I spent hours with Dad on weekends during the day to make sure he was cared for properly.

In my opinion, this is what it takes... lots of dedicated effort by family to ensure your loved ones are safe and well cared for when they are living in a nursing home.

Thank you,

Carol
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