In the days before nursing homes became so highly regulated, many facilities used medications to sedate patients. Elders who were cooperative and slept a lot were easier to manage and required less attention from staff members. Therefore, many nursing homes considered medicating patients to be both efficient and cost effective. While nursing home regulations have come a long way, the practice of misusing certain drugs as “chemical restraints” continues to tarnish the industry’s reputation and factor into families’ long-term care decisions.
Do Nursing Homes Sedate Patients?
Antipsychotics 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 especially dementia patients differently compared to the general population. Some even carry a “black box warning” indicating a high risk of adverse reactions and even death.
Over the past few decades, nursing homes have been subjected to more intense scrutiny regarding safety and quality. Most states, along with the Centers for Medicare and Medicaid Services (CMS) have put strict guidelines in place to govern hygiene practices, the use of restraints and, of course, administration of medications. For example, the 1987 Nursing Home Reform Law protects residents’ rights, including the right to freedom from “physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident’s medical symptoms.”
In 2012, CMS established the National Partnership to Improve Dementia Care in Nursing Homes with the goal of further reducing unnecessary antipsychotic use in these facilities. CMS data reveal that 23.9 percent of long-stay nursing home residents were receiving an antipsychotic medication at the end of 2011. According to the most recent data available, there has been a 39.4 percent decrease to a national prevalence of 14.5 percent as of the fourth quarter of 2020.
There are still many states and regions 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 personal 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 to a resident’s regimen. 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.
My father 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, if they are certified by Medicare and/or Medicaid, must also abide by CMS rules. The staff and internal protocols can vary greatly, so it is crucial for family members to be actively involved in a loved one’s care to ensure they are being treated fairly and getting the attention they deserve.
Monitoring Medication Administration in Nursing Homes
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, Ky., 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.”
Additionally, keep an eye out for any new or unusual diagnoses in a loved one’s chart. A recent investigation conducted by The New York Times found that some nursing homes are using a reporting loophole to continue providing antipsychotic medications to residents. Publicly available CMS data show that use of these medications has steadily decreased over the last decade, but prescriptions for patients with a diagnosis of schizophrenia, Tourette’s syndrome or Huntington’s disease are not included in these numbers. The Times analyzed Medicare data revealing that, “Today, one in nine [nursing home] residents has received a schizophrenia diagnosis. In the general population, the disorder, which has strong genetic roots, afflicts roughly one in 150 people.”
Regardless of whether you find these changes noted in the chart, it’s important to discuss any 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 legitimate 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 interactions 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. In dementia care, both the challenges at hand and the potential solutions are often complex. 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.
However, some symptoms like psychosis and mania are difficult or impossible to manage using non-drug methods. If it turns out that an elder clearly needs a medication to feel better and improve their quality of life, even if only temporarily, why shouldn’t they have it? The Alzheimer’s Association’s recommendations for addressing behavioral and psychiatric symptoms only advise careful usage of psychotropic medications for patients who do not respond to alternative treatments and whose severe symptoms are resulting in physical or emotional harm to themselves or others.
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. Conducting careful research and taking tours to confirm these quality standards is crucial when selecting a senior living community of any kind. There may be 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 your local long-term care ombudsman program and/or the regulatory body for nursing homes in your state. You can find a directory of important resources and contact information organized by state on the National Consumer Voice for Quality Long-Term Care website: TheConsumerVoice.org. It may also be wise to consider moving your loved one to a different facility.